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conservative treatment?

Posted by AllisonL on 1/05/05 at 14:55 (166570)

My orthopedic surgeon told me that I have tarsal tunnel syndrome (the doctor who did the emt and nerve studies said I was definitely having issues with that nerve being irritated but didn't think it was necessarily TTS). It appears that I'm luckier than a lot of you because mainly my pain comes with exercise, for example, I can only play tennis for about 10 minutes before I start limping because of the pain. I do have 2 places near the ankle that if you tap, there's an electric shock that runs up the bottom of my foot and up my 4th toe. I haven't been wearing anything with any type of heel because the slightest incline seems to aggravate it. There's always a bit of swelling right under the ankle I've had 2 cortisone shots that didn't do anything. The nerve study doctor gave 2 suggestions for how to treat it: immobilization and/or physical therapy. The orthopedic said he hasn't heard where that's helped. I'm confused and wonder what type of conservative treatment people have tried and if anyone has had any symptoms similar to mine or is this how their symptoms started and then it progressed. Also, realistically, if I had surgery, how long would it take to be able to play tennis again.

Re: conservative treatment?

Robert B. on 1/05/05 at 18:05 (166580)

I was diagnosed with TTS, Baxters nerve and various other nerve entrapments. Right now I am doing the 'conservative treatment' because of insurance reasons. I too have had the corti-steroid shots with little change. Also, the stretching exercises did nothing for the pain.

I go to physical therapy 3X a week, which has given some relief but not a lot. The physical therapy includes deep massages, ultrasound and aquatics.

The first option was immobilization (casting / cam walker) but I opted not too. I own a horse farm with 10 horses and really can't be down for 4 to 6 weeks during the winter.

According to my Dr., recovery from surgery depends on age, physical condition, weight and activities during recovery. He mentioned anywhere from 1 month to as long a year. Ouch, not in a saddle for a year, I don't like that idea but I am sure my horses wouldn't mind..........

Re: conservative treatment?

Terry D. on 1/05/05 at 20:28 (166583)

I've had the surgery from Dr. Dellon and am about 90% cured from pain....but my foot is numb,tight, sore, I can't really run anymore etc......to make a long story short...unless you are in excruciating pain....which I was.... I wouldn't do the surgery.
I have been getting prolotherapy....my wife swears it is helping her hip which was very painful and arthritic. If I had to do this all over again....at the first symptom....which for me was numbness in the little toe....I'd do prolotherapy first!
Good luck,
Terry D.
I do prolo in Oak Park, IL Dr. Hauser
ps do a google search on prolotherapy if interested

Re: Terry D.

Darlene on 1/05/05 at 21:19 (166588)

Hi Terry.

I'm confused as to how prolotherapy could help TTS. Doesn't it help to tighten ligaments whereas in TTS you need more room for the nerve?

Re: conservative treatment?

LARA on 1/06/05 at 10:03 (166599)

I tried compressions socks and for me they were magic. They aren't for everyone, but they're relatively inexpensive, easy to find, and easy to use. A few people seem to find they actually aggravate the pain, in which case they take off the socks and end the experiment with that treatment.

Re: Allison

Danny DArwin. on 1/07/05 at 10:37 (166635)

I sort of have symtoms like you , not being ablke to stand or walk after 10-15 minutes of being on my feet. I do have more relaxed symptoms when i am resting or sitting and sleeping at night. I have been dealing with this conditiotn for 14 months and have tried all conservative measures. PT, and stretching only aggravated the nerve. I had luck with ART active release therapy, which provided me some relief. It did not take the pain away forever , nbut helped me deal with it. I too am seeing an Orthopaedic surgeron who specializes in the Foot and Ankle at a university medical center. He told me he doesnt see that many of TTS cases, but typically when he does they are from dancers. I am not a dancer. I really liked Bextra because it allowed me to be on my feet for longer periods without tremndoud pain, but these will eat the stomach away and destroy yopur liver.

I have been contemplating surgery and am 50/50 about doing it becaus e all of the neagavtive outcomes i see on this board. I know that everyone is different, and have different doctorsw , but it makes me uneasy to see people are sometimes worse with this surgery. It basically is unpresidfcatble.

Good Luck


Re: Allison

T on 1/07/05 at 14:39 (166654)

I just wanted to tell you good luck with your decision. I've had 2 Tarsal Tunel releases within a years time and had immediate relief from both, however, now 9 months post op I'm finding that the feelings are coming back again. (Tight gripping feeling in the ankle, electric shock type pain down my foot, tight feeling now up to my knee) Keep in mind that everyone heals differenly so my story may not be the same as yours. I do suggest that you go to a doctor that has done many of these proceedures since you are dealing with nurves. I was told by a few top orthopedic's in Philly that that's not to be taken lightly (not that anyone takes surgery lightly).

Re: Allison

LARA on 1/08/05 at 09:17 (166700)

Thought this information might be helpful to you

This is my understanding based on reading this board for several years now:

1. Most people who have TarsalTunnel Surgery are better off aftewards.
-'afterwards' includes a long time for rehabilitation. from weeks to a year
-'afterwards' may last forever, or for a few years, or something in between.
2. Some people are no better and no worse off after surgery & rehabilitation are over.
3. Some people (best guess is about 10%) are worse off.

A. People who have an identifiable mass (scar tissue, tumor) have the most success with surgery.
B. People who have a well organized PT program after surgery, including attention to scar tissue, do best.
C. People who go to a surgeon (be it a podiatrist or orthopedic surgeon) who have done many TT surgeries have a greater likelihood of success.
D. All surgery has risk of infection, scar tissue, and adverse reaction to anesthesia (the anesthesia problem can be avoided by having a neural block - which probably has it's own risks - and I think if you have had anesthesia once without problems, the chances of an adverse reaction go way down). Because the feet are so far from the heart, and therefore has the least efficient blood flow, all healing takes longer (relatively speaking) and has a greater risk of infection.

So, despite the likelihood of success, I think most people on this board suggest as the last option. If you do a search for 'treatments' on this board, you'll probably find a few threads that have LOTS of various treatment options from non-invasive to minimally invasive, to surgery (you may have already seen it).

Good luck with your decision.

Re: conservative treatment?

Ed Davis, DPM on 1/08/05 at 21:51 (166751)

The posterior tibial nerve is compressed to cause symptoms and that can happen in two general ways:
1) A growth in the tarsal tunnel is pressing on the nerve. Removing the growth surgically tends to have a decent success rate.
2)Scar tissue is placing pressure on the nerve. Here is where surgery can be less successful because surgery to release scar tissue may begat more scar tissue and that is why many see symptoms return in this scenario.

An MRI or sonogram can help determine if you are in scenario #1 or #2. For patients in scenario #1, I would recommend surgery. For patients in scenario #2, I would just get rid of the scar tissue via one of the various means available to do so...
A)injections with hyaluronidase - an enzyme that occurs naturally in
our body but can be synthesized and concentrated and injected
around the nerve to reduce scar tissue. A very small amount of
triamcinolone acetonide may be added to the hyaluronidase as it is
a potent form of 'cortisone' that decreases scar tissue, but too
much of it will also atrophy 'good' tissue such as the fatty
tissue that surrounds the nerve, cushions it and lets it glide
B)use of physical therapy modalities that decrease scar tissue such
as ultrasound, phonophoresis
C)very cautiously, certain types of massage--the trick is to massage
the scar tissue around the nerve without traumatizing the already
sensitive nerve.

Re: conservative treatment?

LARA on 1/09/05 at 09:59 (166776)

Thanks for the correction to my post and a better explanation. I think there is another frequent possibility, which is really just a subset of #1. Sometimes there is a varicose vein going throught he tarsal tunnel - which is putting pressure on the nerve. Sometimes this will show up on an MRI and sometimes not.

Re: Scott R

Darlene on 1/09/05 at 15:16 (166798)

This is a great summary courtesy of Dr. Ed.

I wonder if there is a permanet place for it - like the Heel Pain book, but for TTS.

Separately, when I open the website for new messages, I'm getting some from 1992. Do I have to resign in to fix this?

Re: Scott R

Kathy G on 1/10/05 at 09:18 (166840)


If you want to get Scott's attention, I believe you need to use his name as 'ScottR.' Maybe someone else will see this because it might be a lower case 'r' but I know it has to be all one word.

As to getting those old messages, are you talking about hitting the link that says, 'Messages posted since my last visit'? If so, I don't know as there's any way he can change that. I never use that link. I either visit each board individually, if I have the time, or I click on 'View all messages (or words to that effect).' That brings up all the current messages that have been posted on all the boards except the Social Board.

Hope that helps!

Re: conservative treatment?

AllisonL on 1/10/05 at 09:38 (166841)

I had an MRI and an ultrasound before I had the nerve studies...the MRI didn't show anything other than reaffirm what the ultrasound showed which was that the diameter of that nerve was significantly bigger than the diameter of the nerve in the other foot and that I have a chronic sprain in the ankle. That's when we moved on to the nerve studies.
As a result of 2 knee surgeries on my left knee in 1999, I have been walking on my toes for almost 5 years (unbeknownst to me)and I wondered if that had anything to do with it but my orthopedic didn't think it did.

If I haven't had invasive surgery on this foot in the past, would the scar tissue be from sprains and torn ligaments?

(Thanks Ed for the information... )

Re: ScottR

Julie on 1/10/05 at 09:51 (166842)

Kathy, I always used to use 'Messages posted since your last visit' but it has been broken for some time. I've been meaning to email Scott about it - maybe he will see this now that I've closed the space. :)

Re: conservative treatment?

skully on 1/11/05 at 17:00 (166913)

I discussed this with my doctor today - he said that a lot of people - usually without positive nerve tests - do very well with conservative treatment - especially the cast boot. In my case it didn't make a difference whatsoever.

Re: conservative treatment?

Ed Davis, DPM on 1/12/05 at 16:53 (166978)

If you have been toe walking for an extended period of time, the first thing that comes to mind is overuse of the tibialis posterior tendon that runs right next to the posterior tibial nerve. If the tendon swells it can place pressure on the nerve...

Re: Allison

Kara on 1/12/05 at 21:41 (167012)

I had tarsal tunnel release surgery just over a year ago and have had great success with it so far. I am still recoving from the surgery however which can be a little disappointing. About 10 months after the surgery I had some pain start to come back, so my surgeon did a cortisone injection where it hurt and it has been feeling great ever since. I was diagnosed with TTS when I was 18 and was in conservative treatments for over a year before I found a surgeon who would operate. I did have one surgeon back out on the surgery, but I think he didn't really know what he was doing. I think I was an experiment to him. The surgeon I found is located in San Diego, CA and knows this surgery very well. The recovery can be long, but the surgery ws well worth it. It all depends on what you really feel would be best, but it was the only option for me.

Re: conservative treatment?

AllisonL on 1/13/05 at 11:07 (167043)

the only thought then is why one foot and not the other....and how would you treat it... my doctor just gave me a prescription for a gel that was specially compounded that I'm to rub on my ankle 3 times a day and check back with him in 3 weeks. How would you suggest quieting the nerve if it was caused by a swollen tendon? (i've had 2 injections already)

Re: conservative treatment?

Ed Davis. DPM on 1/13/05 at 22:26 (167088)

Why did the knee surgeries casue you to walk on your toes? In other words, we are looking for the underlying cause. Cortisone will only give temporary help if a biomechanical cause underlies the problem.

Re: conservative treatment?

AllisonL on 1/14/05 at 08:41 (167120)

I had 2 surgeries within 6 months on the same knee....first one turned out to be a discoid meniscus (then had blood clot, etc)....Anyway after the first surgery, they weren't able to get my knee to straighten in therapy....I played tennis and was probably walking/running the only way I could. Still had pain, etc in the knee so they went back and cleaned out scar tissue, etc....this time they got my knee 99% straight in therapy. By then, I had developed the habit and nobody said anything and I've been doing it ever since...

Re: conservative treatment?

Ed Davis, DPM on 1/14/05 at 14:58 (167146)

Has anyone checked to see if your calf muscle/achilles has contracted or is too short (physical therpaists can be good at that measuremnet)?

Re: conservative treatment?

AllisonL on 1/18/05 at 13:22 (167470)

no....I'll get someone to check...I know that the achilles on my right foot (the one with the problem) is extremely tight....


Re: Allison

skully on 1/18/05 at 23:55 (167515)

My doctor seems to think the recovery period is about 4 months. ACK
I don't know how many he has done - he's a good podiatrist and caught the thing right on - knew just what it was - but I've got a date of the 11th of FEb and I am about to call them and say oh hell no.

I really feel like my nerve is scarred from my accident. I did have some varicose veins but I just don't feel, deep down inside, like that is causing this. My neurologist thought from my nerve conduction tests that I had scarring too.

I have an osteochondral defect also - with a mass in my ankle and my surgeon has not said if he'd address that or not. He's said though it might take a couple of surgeries for me but I don't like the way that sounds!

I can walk now - just not far and some days are really bad. Some days are good though. I don't want all bad days.

Re: Allison

Kara on 1/25/05 at 13:16 (167908)

I know how you are feeling about the surgery. I had those same feelings, but then it was turning into all bad days, so I had no other option. One doctor wanted to put me on pain management for the rest of my life and I couldn't do that. I was 19 when I had the surgery and that was over a year ago. Even though I can still have a small pain now and then, the surgery was well worth it. I can finally sleep again at night and walk more than 5 steps without pain. My surgeon said that I didn't have any scar tissue, just a bunch of extra veins that had grown after I injured my foot. The surgery is just a personal decision though. You have to decide if it is right for you. But if you are having so much pain that you don't even want to get up to eat or go to the bathroom, I think it is the only option after trying some conventional treatments.

Re: conservative treatment?

Cathy G. on 1/28/05 at 09:15 (168084)

Dr. Davis, My pod. says I have nerve entrapment to inner ankles. I asked if it was tts. He said , 'basically'. He put me on neurontin, and wants me to try and get off my feet(am a nurse). I am already receiving acupuncture so he said he would wait for physiotherapy.
He thinks that the compression is due to rigid orthotics pushing up on the area. It certainly seems better without the orthotics pushing. I am wearing soft inserts. (I have flat feet, and had eswt in fall for longstanding pf).
I have a few questions:
Would swimming help or hinder?
Does the neurontin just control pain or does it help with nerve damage?
Is there any chance that I can go back to work on my feet, but slow down?-I really dont want to have surgery.
And what do you think of prolothereapy?

Re: conservative treatment?

patricia j on 2/09/05 at 11:07 (168796)

Dear Terry D. Could you describe the surgery you had and where your incision was made. Was the tibia nerve decompressed as well as four other nerves. Thanks.

Re: Allison

patricia j on 2/09/05 at 11:20 (168800)

I had tarsal tunnel surgery but I am still in severe pain after 6 weeks. Can you tell me what your surgery entailed and where your incision was made. It's my understanding that not only does the tibia nerve need to be compressed but four other nerves need to be compressed at the same time in order for there to be any relief. Also the incision should be made along the side of the outside of the foot extending from the back down in the side in an 's' shape. Let me know if that was the surgery you underwent. Thanks.

Re: conservative treatment?

NinaL on 2/09/05 at 20:42 (168827)

Sounds familiar. I've been in pain for over a year now. I used to play tennis almost every day. I haven't played in almost a year. I have PF and TTS in both feet. I am on Neurontin & an anti-depressant for the pain. I can't even spend an 30 minutes on my feet at one time without the symptoms occurring. My nerve test shows entrapment of the lateral plantar nerve, which is more rare than the medial plantar nerve. This effects the 4th and 5th toes and the tinels sign is less likely to be present with this type of TTS. I just don't know what to do. Cortisone doesn't work. My podiatrist doesn't think immobilization will help and could possibly make it worse. I was thinking of getting the Indoscopic PF release done just to see if it would help. Really don't want to go with TTS surgery. My podiatrist said he could do both feet at the same time (I don't think so).

Hope you get some relief soon. I know us die-hard tennis fans can get really grumpy when we don't get our fix!