Tarsal Tunnel Help

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Hi everyone,

I am a new practioner here in VA I often read the posts here that are extremely informative! I need some help so here goes..
I have a 28yro pt with what I believe is tarsal tunnel syndrome. She had a car accident 1 month ago, and began to experience some pain a week or so later. I took xrays and did not appreciate any fx, lisfrancs appears intact also. She has positive tinel's, numb shooting pains to her plantar foot. I put her in an equalizer brace, I did apply unna boot for 2 weeks for support, tried NSAIDS, gave her 2 PT blocks with dex (which gave her relief for about 2 days each time) I now have her on Neurontin 600mg qhs, she is not feeling much better. I had discussed MRI and possible surgery but she is reluctant to these suggestions. Can anyone suggest anything else I could try apart from increasing her neurontin? What about fentanyl/lidoderm patch?

 

Hi Damsel:
As you know, there are quite a few underlying etiologies for TT. It's interesting that this patient's is related to an injury. What's your best guess as to the relationship? Does this patient have any symptoms / trauma more proximal?

Assuming your patient's symptoms are originating from the TT, an injury could cause any number of transient etiologies....hematoma, simple intratarsal tunnel swelling, acute synovitis, etc....

In my opinion, duration of symptoms of only 1 or 2 months is a bit early to start discussing surgery. I would not hesitate ordering an MRI. If your patient refuses this, then let her treat herself. Simply put, in order to give her the best TREATMENT you need an accurate DIAGNOSIS.

Steve

 

Thanks Steve for your input!

 

There are a few other considerations I would investigate. Since she was in a car accident, you also have to look into the possibility that the etiology may be from a radiculopathy if there was any possible back/spine involvement during her accident.

Many times the treatment is focused where the symptoms are presented, but upon further probing it can be discovered that there may have been a "silent" injury more proximally. You may want to have her examined by a good physiatrist for a comprehensive exam to rule out a more proximal injury contributing to her symptoms.

Additonally, although an EMG/NCV can often be negative in the early stages of a nerve entrapment/neuropathy, since there are no degenerative changes (Wallerian degeneration) early in the process, you may still want to consider ordering an EMG/NCV to see if during the accident there was an acute injury to the nerve with actual damage.

As per Steve, this is way to early in the treatment process to consider surgical intervention.

And after over 20 years in practice, I would caution you as a young practitioner to never "rush" into TTS surgery. I believe most seasoned docs would agree with me when I state that when it comes to TTS surgery there are usually two results: 1) patients that obtain complete relief and live happily ever after, 2) patients that end up with chronic and significant pain. There are rarely patients that fall in the middle and obtain "some" relief.

So explore ALL options and as per Steve's comments, never let a patient dictate the treatment plan. It's OK for a patient to be involved with making decisions, but they can't dictate your treatment. If a patient refuses your treatment recommendations, such as MRI's, tests, procedures, etc., that's not a patient you ever want to take to the O.R., let alone continue treating.

David

 

Thank you for your advice David. The patient has called and cancelled her appt as she is feeling better with Neurontin but I cannot keep her on this forever. I will be more assertive from now on as far as my treatment plan goes, your input was greatly appreciated.

 

Practice management tip: Don't let patients like this "cancel", but make sure that they simply "reschedule" for a later date!

This isn't a money/economic issue. This is to simply assure that your patient's condition remains monitored. Patient's often "cancel" appointments when they begin to feel some relief, then you will get a call as an urgency/emergency if and when the symptoms return full force.

TTS is one of those conditions that you want to keep in check, and do not want to allow the condition to worsen. Therefore, at the very least I would make a note to call this patient in 2-3 weeks to see how she is doing, and if she's still having any problems encourage her to return to the office for further evaluation and treatment.

 

Will do, thank you.