10/09/2014    Howard J. Bonenberger, DPM

Varicosities as a Cause of Tarsal Tunnel Syndrome

I have found the following approach helpful in
this difficult situation. Of course not all
patients will be able/willing to do this but many
that do find it beneficial. Explain that you are
looking to manage the problem without surgery
however in some cases decompression is needed. A
very simplified illustration of a cross-section
of the tarsal tunnel is helpful. Discuss why
their pain is often worse in the evening and
while in bed (pooling and venous engorgement
worsen throughout the day).

Examine the patient at an early morning
appointment and again at a late afternoon or
evening appointment...compare their subjective
symptoms and your exam findings. Ultrasound of
the tarsal tunnel at those different visits may
also show significant engorgement at the later
visit.

1. Ask the patient to lay down and elevate the
feet at about 30 degrees for 10 minutes per hour
from mid-afternoon until bedtime for 1 week as a
"trial"...some will find it helpful and stick
with it. Laying on the floor with the feet on a
couch or bed will work. Ask them to keep a simple
log of their symptoms. Caution those with PAD,
CHF and pulmonary edema about risks (document
that discussion).

2. Elevate the foot of the bed 2 inches while
sleeping. Use a few boards under the legs of the
bed...pillows under the calves or knees will
fail. Caution those with PAD, CHF or pulmonary
edema about risks. Even 1 inch is better than
level.

3. Counsel them about the daily use of an OTC
knee-high compression stocking. These must be
applied prior to arising in the morning...take
the shower at night before bed so they can get
the stockings on before the edema begins to
accumulate.

4. Horse chestnut extract may work to increase
flow between the superficial and deep veins and
reduce engorgement.

5. Stress to them that they cannot cherry-pick
and only do what is convenient for them if they
truly want to find relief (good luck with that
one).

If all else fails then surgical decompression for
venous engorgement is often helpful. Open the
laciniate ligament cautiously, use a bipolar
cautery unit as needed, and close the skin with
horizontal mattress Prolene sutures left in for 3
weeks. I am speaking strictly about decompression
of venous pressure, not complete release of all
four branches of the PTN.

Howard J. Bonenberger, DPM, Nashua, NH,
howardbon1@gmail.com

Other messages in this thread:

---

10/09/2014    Howard J. Bonenberger, DPM

Varicosities as a Cause of Tarsal Tunnel Syndrome

I have found the following approach helpful in
this difficult situation. Of course not all
patients will be able/willing to do this but many
that do find it beneficial. Explain that you are
looking to manage the problem without surgery
however in some cases decompression is needed. A
very simplified illustration of a cross-section
of the tarsal tunnel is helpful. Discuss why
their pain is often worse in the evening and
while in bed (pooling and venous engorgement
worsen throughout the day).

Examine the patient at an early morning
appointment and again at a late afternoon or
evening appointment...compare their subjective
symptoms and your exam findings. Ultrasound of
the tarsal tunnel at those different visits may
also show significant engorgement at the later
visit.

1. Ask the patient to lay down and elevate the
feet at about 30 degrees for 10 minutes per hour
from mid-afternoon until bedtime for 1 week as a
"trial"...some will find it helpful and stick
with it. Laying on the floor with the feet on a
couch or bed will work. Ask them to keep a simple
log of their symptoms. Caution those with PAD,
CHF and pulmonary edema about risks (document
that discussion).

2. Elevate the foot of the bed 2 inches while
sleeping. Use a few boards under the legs of the
bed...pillows under the calves or knees will
fail. Caution those with PAD, CHF or pulmonary
edema about risks. Even 1 inch is better than
level.

3. Counsel them about the daily use of an OTC
knee-high compression stocking. These must be
applied prior to arising in the morning...take
the shower at night before bed so they can get
the stockings on before the edema begins to
accumulate.

4. Horse chestnut extract may work to increase
flow between the superficial and deep veins and
reduce engorgement.

5. Stress to them that they cannot cherry-pick
and only do what is convenient for them if they
truly want to find relief (good luck with that
one).

If all else fails then surgical decompression for
venous engorgement is often helpful. Open the
laciniate ligament cautiously, use a bipolar
cautery unit as needed, and close the skin with
horizontal mattress Prolene sutures left in for 3
weeks. I am speaking strictly about
decompression of venous pressure, not complete
release of all four branches of the PTN.

Howard J. Bonenberger, DPM, Nashua, NH,
howardbon1@gmail.com