Dr. Michael E. GrahamDr. Michael E. GrahamPodiatric Physician and Surgeon of the Foot and Ankle

Fellow, American College of Foot and Ankle Surgeons, Fellow, International Peripheral Nerve Surgeons, Diplomat, American Board of Podiatric Surgery.

Private Practice, Birmingham and Shelby Township, Michigan

New Hope New Hope forfor

Peripheral Neuropathy Peripheral Neuropathy

What is Neuropathy?What is Neuropathy?

NeuroNeuro- something doing - something doing with the nervous systemwith the nervous system

--pathypathy- there is a problem- there is a problem

A very generic term A very generic term meaning that something is meaning that something is wrong with the nervous wrong with the nervous systemsystem

What is Peripheral Neuropathy?What is Peripheral Neuropathy?

Problem with a nerve Problem with a nerve outside of the spineoutside of the spine

Usually a problem in Usually a problem in the hands/feetthe hands/feet

A very non-descriptive A very non-descriptive termterm

Leaves the patient and Leaves the patient and doctor guessing as to doctor guessing as to what is the problem.what is the problem.

Nerve AnatomyNerve Anatomy

What do I feel?What do I feel?

PainPain

NumbnessNumbness

CombinationCombination

Symptoms Depends on which nerve Symptoms Depends on which nerve fibers are being affectedfibers are being affected

Symptoms of Foot/Ankle InvolvementSymptoms of Foot/Ankle Involvement

Typically starts as Typically starts as numbness/strange feeling under numbness/strange feeling under the toes or ball of the foot.the toes or ball of the foot.

Usually occurs during Usually occurs during walking/runningwalking/running

Subsides when the activity is Subsides when the activity is stoppedstopped

Feeling that the sock is Feeling that the sock is loose/wrinkled under the toesloose/wrinkled under the toes

SymptomsSymptoms

Foot is “awake” in the Foot is “awake” in the AM when first get out AM when first get out of bed.of bed.

As the day progresses As the day progresses the numbness starts.the numbness starts.

After retiring for the After retiring for the night, feet “wake-up”night, feet “wake-up”

Feet are “awake” when Feet are “awake” when first get out of bedfirst get out of bed

Go numb pretty quickGo numb pretty quick After going to bed, feet After going to bed, feet

“wake-up” after 30 to 60 “wake-up” after 30 to 60 minutes-feel like bugs are minutes-feel like bugs are crawling on the bottom of crawling on the bottom of the feetthe feet

After a prolonged period After a prolonged period of this, when the nerve of this, when the nerve “wake-up” they “wake-“wake-up” they “wake-up” with a vengeance. up” with a vengeance.

After a while the feet After a while the feet are extremely sensitive.are extremely sensitive.

Toes are very cold Toes are very cold during the day and are during the day and are on “fire” at nighton “fire” at night

Can’t stand the touch of Can’t stand the touch of their sheets to touch their sheets to touch their feet.their feet.

Eventually, the feet are Eventually, the feet are numb all the timenumb all the time

Numbness starts in the Numbness starts in the toestoes

Slowly works it way to Slowly works it way to the arch of the footthe arch of the foot

Loss of sensation to the Loss of sensation to the heelheel

Starts to then travel up Starts to then travel up the lower legthe lower leg

Typical Patient BackgroundTypical Patient Background

Active lifestyle- lots of Active lifestyle- lots of walking/standingwalking/standing

May or may not be a May or may not be a diabeticdiabetic

May or may not have had May or may not have had chemotherapy/radiationchemotherapy/radiation

Usually have a lower than Usually have a lower than normal arch, or high arched normal arch, or high arched foot.foot.

What kind of damage is occurring to What kind of damage is occurring to the nervethe nerve

There are signs of vascular There are signs of vascular damagedamage

There is damage of/to the There is damage of/to the nervenerve

Enlargement of the nerveEnlargement of the nerve Shrinkage of the nerveShrinkage of the nerve Nerve death-discontinuity of Nerve death-discontinuity of

the nerve the nerve

Nerve AnatomyNerve Anatomy

Posterior Tibial Nerve

1st Area of Damage2nd Area of Damage

Why does this occur?Why does this occur?

There is chronic overstretching There is chronic overstretching of the nerveof the nerve

There is chronic compression of There is chronic compression of the nervethe nerve

There is chronic overstretching There is chronic overstretching and compression of the nerveand compression of the nerve

The ProblemThe Problem

Chronic Chronic

Overstretching of the Nerve(s)Overstretching of the Nerve(s)Compression of the Nerve(s)Compression of the Nerve(s)

Nerve Damage CycleNerve Damage Cycle

When we walk with abnormal mechanics to the foot, this leads When we walk with abnormal mechanics to the foot, this leads to an overstretching of the posterior tibial nerve.to an overstretching of the posterior tibial nerve.

When there is no motion to the foot, the nerves channels are When there is no motion to the foot, the nerves channels are open and nerve impulses are traveling through the nerves.open and nerve impulses are traveling through the nerves.

After a period of overstretching and compression the nerve After a period of overstretching and compression the nerve fibers stop functions and there is decreased sensation to the fibers stop functions and there is decreased sensation to the nerves.nerves.

Once the overstretching/compression stop, the nerve will Once the overstretching/compression stop, the nerve will eventually recover and sensation will return to the foot.eventually recover and sensation will return to the foot.

As time goes on, however, damage is occurring to the nerves As time goes on, however, damage is occurring to the nerves and they will take longer to recover until permanent damage and they will take longer to recover until permanent damage occurs and the feet are always numb.occurs and the feet are always numb.

Degeneration of the NerveDegeneration of the Nerve

Carpal Tunnel SyndromeCarpal Tunnel Syndrome

80% of cases have involvement 80% of cases have involvement of the wrists as well as the feet.of the wrists as well as the feet.

It is simply a chronic It is simply a chronic compression of the nerve.compression of the nerve.

The nerves are being strangled, The nerves are being strangled, they is why the scream and they is why the scream and kick when possible to let us kick when possible to let us know that something is wrong.know that something is wrong.

Tarsal Tunnel SyndromeTarsal Tunnel Syndrome

Tarsal Tunnel is the Tarsal Tunnel is the carpal tunnel of the foot.carpal tunnel of the foot.

Due to chronic Due to chronic compression of the compression of the nerves to the inner anklenerves to the inner ankle

How do we diagnose this?How do we diagnose this?

Nerve Conduction Tests Nerve Conduction Tests (NCV)(NCV)

Eletromyograms Eletromyograms (EMGs)(EMGs)

Test for diabetesTest for diabetes Tests for other medical Tests for other medical

conditionsconditions

Apply pressure to the Apply pressure to the tarsal tunnel- usually tarsal tunnel- usually there is painthere is pain

Test vibratory sensors Test vibratory sensors of the foot (VPT)of the foot (VPT)

RadiographsRadiographs Gait analysis Gait analysis

Treatment of NeuropathyTreatment of Neuropathy Usually told “We don’t know Usually told “We don’t know

why you have it!”why you have it!” We can give you pills to try to We can give you pills to try to

help (meanwhile it just gets help (meanwhile it just gets worse), pills are expensive, worse), pills are expensive, usually just take off the “edge”usually just take off the “edge”

Keep coming back for more Keep coming back for more testingtesting

You will most likely become a You will most likely become a diabetic if not already diabetic if not already diagnosed (not true)diagnosed (not true)

Current Forms of TreatmentCurrent Forms of Treatment

Biannual testing

Extra depth shoes NSAIDS Pain pills Nerve Pills Psychiatry Wheelchair/walker

Shows increased nerve damage

Prevent ulceration Do nothing Barely take off the edge See next slide Loosing battle Syndrome X- further

decrease in activity

What is the New Hope?What is the New Hope?

Decompression of the Decompression of the compressed nervescompressed nerves

Carpal tunnel release in Carpal tunnel release in the wrist, tarsal tunnel the wrist, tarsal tunnel release in the footrelease in the foot

This photo is like a nerve being damaged by the overlying tissues. The damage starts superficially and continues within the nerve.

The goal is to release the tissues damaging the nerve. Thank goodness nerves can repair themselves if given a chance, unlike this fallen tree. The longer the tissues destroy the nerves the more damage is done to the nerve.

Surgical DecompressionSurgical Decompression

Cross Over EffectCross Over Effect

This is real not imaginary.This is real not imaginary. The damaged nerves of one foot affect the The damaged nerves of one foot affect the

opposite foot.opposite foot. Scenarios:Scenarios:

Good-Good- Bad-Bad- Ugly-Ugly-

Cross Over Effect Cross Over Effect - - GoodGood

By decompressing one foot not only is there is By decompressing one foot not only is there is improvement on that side there is also improvement on that side there is also improvement in the contra-lateral limb.improvement in the contra-lateral limb.

IF sensation/symptoms are restored to the IF sensation/symptoms are restored to the contra-lateral limb there is not need for tarsal contra-lateral limb there is not need for tarsal tunnel decompression or neurolysis of the tunnel decompression or neurolysis of the nervesnerves

Cross Over Effect Cross Over Effect - - BadBad

Surgery to the foot yield minimal results with Surgery to the foot yield minimal results with no change in the contra-lateral limbno change in the contra-lateral limb

The opposite limb is the dominate nerve The opposite limb is the dominate nerve pathology and once that side is also pathology and once that side is also decompressed there should be an additional decompressed there should be an additional effect on both feet.effect on both feet.

Must warn patients about this prior to surgery.Must warn patients about this prior to surgery.

Cross Over Effect Cross Over Effect - - UglyUgly Nerve decompressions are performed on both Nerve decompressions are performed on both

feet (one at a time) and no results are felt.feet (one at a time) and no results are felt. Don’t take the patient’s word for it. Must Don’t take the patient’s word for it. Must

perform nerve testing prior to surgery and perform nerve testing prior to surgery and routinely post-op.routinely post-op.

Their nerves may be so severely damaged that it Their nerves may be so severely damaged that it was too late.was too late.

No matter how severe I will still attempt.No matter how severe I will still attempt. It just may takes years for the results to be felt.It just may takes years for the results to be felt.

Complications of SurgeryComplications of Surgery

Wound dehiscenceWound dehiscence Scar tissue formationScar tissue formation

HematomaHematoma InfectionInfection Temporary increase in nerve symptomsTemporary increase in nerve symptoms

2% revision rate2% revision rate

Complications of:Complications of:

““Supervised Neglect”Supervised Neglect”Doing NothingDoing Nothing

Increased Nerve PainIncreased Nerve Pain Loss of SensationLoss of Sensation UlcerationUlceration Bone infectionBone infection AmputationAmputation Charcot’s FootCharcot’s Foot

Decreased Activity LevelDecreased Activity Level Decreased metabolismDecreased metabolism Increased Weight (obesity)Increased Weight (obesity) DiabetesDiabetes HypertensionHypertension Arterial DiseaseArterial Disease

What about the Hyperpronation?What about the Hyperpronation?

HyperpronationHyperpronation- The most common - The most common consistent finding/etiology of nerve consistent finding/etiology of nerve

compression syndrome.compression syndrome.

The Correction-must internally The Correction-must internally straighten the foot.straighten the foot.

Hyperpronation-the cureHyperpronation-the cure

Abnormal/Before After/Restored

NormalHyProCure

Abnormal Closure of the spaceAbnormal Closure of the space

Post-Op CoursePost-Op Course

3-5 days minimal walking3-5 days minimal walking 7-10 days increased walking-but still limited7-10 days increased walking-but still limited 2-3 weeks relatively normal walking2-3 weeks relatively normal walking 4-6 weeks no limitation, residual soreness4-6 weeks no limitation, residual soreness 2-3 Months Running/Jogging2-3 Months Running/Jogging 1 year fully recovered1 year fully recovered

What are the resultsWhat are the resultsIt depends on:It depends on: how long has the symptoms how long has the symptoms

has been presenthas been present How much nerve damage has How much nerve damage has

been donebeen done What other medical What other medical

deformities are presentdeformities are present The health of the patientThe health of the patient Patient compliancePatient compliance

When will the results be felt?When will the results be felt?

Usually the severe pain at Usually the severe pain at night is instantly resolvednight is instantly resolved

The return of feeling to the The return of feeling to the foot can take a very long foot can take a very long time to return it ever.time to return it ever.

If the nerve fibers are If the nerve fibers are completely destroyed the completely destroyed the feeling may never returnfeeling may never return

Other times there is instant Other times there is instant feeling in the foot.feeling in the foot.

What are the Potential Complications?What are the Potential Complications?

Delayed incision Delayed incision healinghealing

InfectionInfection No return of feelingNo return of feeling Further nerve damageFurther nerve damage Scar tissueScar tissue

What are the Potential Complications What are the Potential Complications of Not Having these Procedures of Not Having these Procedures

PerformedPerformed Progression of the painProgression of the pain Nerve disintegrationNerve disintegration Complete numbness in the foot.Complete numbness in the foot.

THEN at risk forTHEN at risk for Ulceration and other severe bone deforming Ulceration and other severe bone deforming

diseases, infection, loss of limb.diseases, infection, loss of limb.

There is indeed New Hope For There is indeed New Hope For Peripheral NeuropathyPeripheral Neuropathy

It is not a mystery anymoreIt is not a mystery anymore Medications only mask the Medications only mask the

symptoms, meanwhile, the nerve symptoms, meanwhile, the nerve damage continues to occurdamage continues to occur

The sooner surgical decompression is The sooner surgical decompression is performed, the sooner nerve healing performed, the sooner nerve healing can occurcan occur

The risks of not having the The risks of not having the decompression/stent procedure far decompression/stent procedure far outweigh the risks of having the outweigh the risks of having the procedures performed.procedures performed.

thanksthanks