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Interesting Case #2

Discussion in 'Foot Surgery' started by drsarbes, Nov 25, 2008.

  1. drsarbes

    drsarbes Well-Known Member


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    40 ish year old female with pain in the 2-4th toes left foot.
    Original Dx was a Morton's neuroma and treated with Cortisone injections and orthotics.

    When she failed to respond she obtained another opinion. At this time she also noticed some "swelling" in her ankle area.
    A DxUS was done and a Dx of ganglion was made.
    The patient at that point was referred to me for Surgical excision.
    Approx. 4 cc's of fluid was aspirated and her symptoms completely resolved for two months when her cyst refilled. Another aspiration yielded the same results.

    Surgery was then carried out.
    The cyst was indeed intra tarsal tunnel coming of the flexor tendon sheath and adhered to the Posterior Tibial nerve.

    Here are some intra operative photos.

    Steve
     

    Attached Files:

  2. bob

    bob Active Member

    Nice one Steve.

    In your standard examination/ diagnostic workup of forefoot pain with neuroma-like symptoms, do you routinely check the tarsal tunnel out? And if so, what do you do (eg. tinel's, valliex, palpation for space occupying lesions, NCV's)? I must say, it's something that I'm sure to have missed at some point in the past and it's good to see someone putting the pictures up here to prove that not all neurogenic forefoot pain is down to an intermetatarsal neuroma.

    What's your post op management like? Do you cast them and how long non-weighbearing?
     
  3. drsarbes

    drsarbes Well-Known Member

    Hi Bob:
    I think everyone should R/O a Tarsal Tunnel syndrome as well as other Nerve etiologies when confronted with neurological symptoms in the forefoot. In particular, patient's presenting with forefoot and or digital nerve pain who have not responded to previous localized treatment. We should all take the blinders off.

    A good example is a patient I saw several years ago with intense pain in his 5th digit of the left foot, plantarly. He had several treatments from several clinics for everything from hammer toe to neuroma to 5th MTPJ synovitis, gout, and RSD. When I saw him he had a pronounced Tinel's Sign at the Tarsal Tunnel radiating ONLY to the 5th toe. No one had checked this in the 1 or 2 years he had had symptoms.
    We ended up doing a Tarsal Tunnel release which resolved his pain.

    To answer your question: I think you get suspicious of a Tarsal Tunnel Syndrome with forefoot pain just by taking the history. I have found patients will complain of much more severe pain and more of an inability to "live with the pain" when it originated from a more proximal location.

    A very diagnostic test you can perform to R/O Tarsal Tunnel etiology is to inject 1cc plain decadron into the tarsal Tunnel; if the symptoms are improved OR aggrevated, this is a positive sign for TTS. These injections are normally pain free to administer, however, if a patient has a very what I call INTENSE tarsal tunnel syndrome even inserting the needle will add enough pressure to enhance the symptoms.

    Steve
     
  4. Steve:

    Nice photos again. I always find it very interesting removing soft tissue masses from the foot. They are all unique in size and shape and anatomical location.

    Keep the cases coming!
     
  5. simonf

    simonf Active Member

    Steve, nice pics again btw,
    just out of curiosity does the injected agent need to be a steroid, wouldnt any additional volume of liquid in the area create the same effect?

    simon
     
  6. drsarbes

    drsarbes Well-Known Member

    Hey Simon:
    Yes, any volume introduced would have an effect, however, not all the Tarsal Tunnels are that sensitive. In addition, the injection is still primarily a therapeutic one, although most of the times it only serves to be diagnostic, i.e., short term relief or increased symptoms. It is nice when a patient receives long term relief, and for that you do need the cortisone.

    Steve
     
  7. simonf

    simonf Active Member

    Hi Steve,

    Maybe I misinterpreted your original post, I thought maybe you were using this as a diagnostic indicator. I have done a few tarsal tunnel injections and have always prepared folks for a worsening in the short term because of the volume of the shot, which they often seem to get!

    simon
     
  8. drsarbes

    drsarbes Well-Known Member

    Hi Simon:
    I normally inject 1cc plain decadron. No anesthetic.
    I've always rationalized that if I injected .5% marcaine with a steroid then I would get some short term relief due only to the fact that I was numbing the area; this wouldn't help me with verifying a diagnosis.
    Injection plain steroid cuts down on the volume plus I can determine that any improvement is most likely due to the antiinflammatory effects of the decadron.

    Steve
     
  9. drsarbes

    drsarbes Well-Known Member

    saw this patient two weeks post op.
    She's been in a Partial Weight Bearing boot cast.
    She is doing quite well and did not need any pain meds post op.
    We will place her in a CAM type boot for another two weeks with crutch assistance.

    Steve
     
  10. Dr. DSW

    Dr. DSW Active Member

    Dr. Arbes,

    Interesting case. Do you ever utilize diagnostic ultrasound or MRI to assist you or help you "plan" your surgery prior to going to the O.R. so there are no intra-operative surprises?

    From past experience I know that the tarsal tunnel can be extremely tricky with a lot of "surprises" from lipomas, to cysts, to large varicosities to accessory muscles entering the tunnel. I have found it very useful to have diagnostic testing prior to entering the O.R. so I have a pretty good idea of the anatomy/pathology in the tunnel prior to my incision. I've found it very useful and pretty accurate.
     
  11. drsarbes

    drsarbes Well-Known Member

    "Interesting case. Do you ever utilize diagnostic ultrasound or MRI to assist you or help you "plan" your surgery prior to going to the O.R. so there are no intra-operative surprises?"

    Hi DR DSW:
    On this patient I did have an Ultrasound from her referring doctor.

    I don't normally obtain MRIs for tarsal tunnels unless I suspect a mass or varicosities.

    Steve
     
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