Neuropathy is a generic term and is untreatable. Peripheral nerve compression is more specific and is cureable. Lets end Neuropathy.

1. NeuropathyvsPeripheral Nerve Compression Syndrome Michael E. Graham, DPM, FACFAS

2. Neuropathy What do we know? Nothing- no solution Your situation will only get worse We don’t like seeing these patients in our office Chronic complainers Hopeless 20 million Americans with symptoms

3. Peripheral Neuropathy What is the etiology? Over 100 etiologies of peripheral neuropathy Diabetes ? Alcohol ? Chemotherapy ? Heavy Metal Poisoning ? Hereditary ? Idiopathic ? WE REALLY DON’T KNOW

4. Diabetic Peripheral Neuropathy 28 to 60% of Type I or II diabetics develop Neuropathy (Young et al 1993) Sorbital Accumulation- not proven, theoretical PolyolPathyway: oxidative stress, mitochondrial dysfunction, and ischemic nerve damage Treatment aimed at: Controlling hyperglycemia Foot inspection Controlling pain End result- Continued progression and worsening of the condition

5. Diabetic Peripheral NeuropathySymptoms Numbness or insensitivity to pain or temperature Tingling, burning, or prickling sensation Sharp pains or cramps Extreme sensitivity to touch, even a light touch Loss of balance and coordination Symptoms are worse at night Muscle weakness (intermetatarsal)- digital deformities

6. Diabetic Neuropathy Loss of Sensory Protection 15% develop ulceration 12-24% require amputation 80% of diabetics who present with ulceration have decreased sensation in there foot/feet.

7. Alcoholic Neuropathy Persons who consumed large quantities of alcoholic beverages over an extended period of time. Symptoms are the same as diabetic and other neuropathy- Incidence - unknown Treatment- basically the same as DPN and “Stop Drinking”

8. Drug-Induced & Toxic Neuropathy Medications Disulfiram Metronidazole Phenytoin Cisplatin Statins Rare- 2-4% Symptoms- Same as other Forms of neuropathy Lead & Heavy Metals Arsenic Mercury Thallium Symptoms resemble the same as other forms of metabolic, compression, etc.

10. What Do We Know? Damaged microvasculature Decreased oxygen to specific parts of the nerve Areas of chronic flattening Signs of chronic inflammation Perineurial swelling Sites of specific nerve damage Sites of nerve repair

11. What IF…. A Patient presents with heel pain. Diagnosis of Plantar Fasciitis What if they also a history of: Diabetic Alcoholic had a family member with a history of plantar fasciitis worked with heavy metal had chemotherapy. What difference does it make?

12. What if someone with chronic condition was told that nothing could be done for them? Patient is hopeless Treatment options are useless We can help try to relieve the pain It will only get worse We don’t know why you have developed this

13. Let’s rethink the situation

14. Peripheral Nerve CompressionSyndrome I think that this is going to make a lot of sense Let’s change the way we think about neuropathy!

15. Peripheral Nerve CompressionSyndrome Chronic Damage to a peripheral nerve Mild Moderate Severe Ever heard of Carpal Tunnel Syndrome?

16. Carpal Tunnel Syndrome Chronic Repetitive Compression & Overstretching Leads to Median Nerve Damage

17. Symptoms Pain Numbness Tingling Pain to palpation of the carpal tunnel Sound familiar

18. Carpal Tunnel Syndrome Conservative measures NSAIDS Immobilizing braces Physiotherapy Localized steroid injections Long term efficacy usually alter/eliminate motion.

19. Surgery Treatment of choice Better out comes than wrist splinting Claim 90% success in eliminating symptoms

20. What are the Patient’s Symptoms? Feet feel best in the morning As the day goes on they get worse “The more active I am the worse the symptoms” At night when I go to bed they really start acting up Numbness/burning in my toes/ball of foot Travels into my arch and up my leg Top of the foot feels fine, no problems there Used to happen after walking on the treadmill/mall but would stop after resting.

21. Typical Patient Usually has been to many other doctors first. (even though it is a foot symptom). Has had many expensive tests with or without abnormal findings Frustrated Very fearful Middle aged or older Have a history of excessive walking/standing House wife Postal worker Etc.

22. WHY WHYWHYWHYWHYWHY Do their feet feel their best in the morning? Why do their feet become more symptomatic as the day goes on or with increased activity? Why are the symptoms worse at night? Thesymptoms first started in the toes/ball of the feet Slowly after months/years went to the arches and up the leg

23. There really is no mystery. This is a nerve problem. What nerve supply is being affected?

24. Do you ever have these patients stand or walk?

25. Walking- the 2nd most common thing we do.

26. Excessive Rearfoot Motion

27. Symptomatology The outer part of the posterior tibial nerve fibers lead to the tip of the plantar part of the toes Deeper fibers correlate to the ball/arch of the foot.

28. Road Map to Diagnosis IF the patient can tell us where the symptoms are occurring then we should be able to figure out which nerve is being affected.

29. Keep It Simple Can you tell me which blood vessels are not working? Let’s use the same rational with the nerves

30. Nerve Anatomy

31. Peripheral Nerve Parts

35. Peripheral Nerve Damage(Double Whammy) A nerve can only stretch so far Chronic overstretching will lead to damaged blood flow A nerve can only be compressed so many times until there is partial nerve impairment Chronic compression leads to direct nerve damage (myelin).

36. Just like any other soft tissue of the body A peripheral nerve can take SOME trauma without completely falling apart HOWEVER it can only take so much before pathology ensues.

37. If ignored or left untreated or improperly diagnosed the symptoms as well as the damage to the structure will progress.

38. Nerve Pathology

40. Graham International Implant Institute, Inc. Functional Anatomy Entire weight of body travels through the talus. Redirected from the tibia and fibula to the Calcaneus and Navicular bones.

41. Graham International Implant Institute, Inc. Sinus Tarsi Fulcrum point Should always stay “open” Abnormal closure of this space leads to deformity.

42. Graham International Implant Institute, Inc. PathoMechanics Obliteration of the sinus tarsi Plantar flexion of the talus Abnormal forces directed throughout the foot.

43. Graham International Implant Institute, Inc. Abnormal Talar DeviationLeads to Excessive Rearfoot Motion. Medial Anterior Plantarflexion

44. Excessive Rearfoot MotionLeads to: Chronic Overstretching of the soft tissue to the rearfoot Can lead to compression of the posterior tibial nerve and it’s terminal branches.

45. We are familiar with the Tarsal Tunnel.

46. Actually 2 areas of Compression Posterior Tibial Nerve 1st Area of Damage 2nd Area of Damage

47. So what’s the Good Newsis there any hope left.

48. Peripheral Nerves Can REGENERATE.

49. Putting the whole puzzle together

50. Nerve Damage Cycle The most common thing we do besides breathing is walking Excessive rearfoot motion leads to chronic overstretching and compression of the posterior tibial nerve and its terminal brances By 50 years of age we have taken 180,000,000 steps

51. PN Damage- continued This is a gradual onset problem If left untreated will continue to develop more nerve damage Exercise/walking/standing leads to further damage At night we are not traumatizing the nerves which is why these patients symptoms are not as bad when they get out of bed in the morning

52. As the day progresses, more damage is caused to the nerve due to increased activity until….nerve goes numb At night when going to be the patient stops traumatizing the nerves and the “wake-up” with a vengeance. Some patients have to get out of bed and find if they walk for a while the pain subsides. Why? They are “re-numbing” their nerves.

53. The Fix

54. First part is to release the fibers that are “strangling” the nerves.

55. Surgical Decompression

56. Soft Tissue DecompressionPart One Release the Lacinent Ligament-Proximal to Distal, start in the middle and work out from there. Use your pinkie Do not need to necessarily work your way to dissect the PTN and its terminal branches.

57. Surgical DecompressionPart Two Go distal through the portapedis. Usually have to create an opening, I use tenotomy scissors. Stick your pinkie into the portapedis. To show what effect hyperpronation has maximally pronate the foot with your pinkie in the portapedis- carefully (I am not responsible for crushed pinkies!)

58. I feel that it isn’t essential to go in and dissect out the nerves. As long as we “free-up” the neurovascular bundle the nerves will no long be crushed. If we perform too much dissection around the nerve it is possible to form scar tissue If we don’t do enough dissection it is possible to miss some of the fibers that are destroying the nerves.

59. How do we control the Excessive Rearfoot Motion?

60. Closer look at excessive hindfoot motion-hyperpronation

61. Weightbearing AP FluoroscopyRCSP showing transverse plane correction

62. Graham International Implant Institute, Inc. NWB to WB

63. Hologic Insight Mini C-arm Graham International Implant Institute, Inc.

64. Graham International Implant Institute, Inc.

65. Minimal weight with foot in ideal position versus full weight and abnormal position. Graham International Implant Institute, Inc.

66. Graham International Implant Institute, Inc.

67. HyProCure®Extra-Osseous TaloTarsal Stabilization Device Threaded portion locks the implant into the cervical ligament in the canalis portion of the sinus tarsi Tapered portion abuts the lateral aspect of the canalis tarsi for accurate placement. Outer wider diameter prevents obliteration of the sinus tarsi. Grooved section allows for fibrous tissue in-growth to prevent backing-out of the implant. Made of medical grade titanium Cannulated for guide wire insertion for accurate placement within the sinus tarsi. Graham International Implant Institute, Inc.

68. Before/After Graham International Implant Institute, Inc.

69. Graham International Implant Institute, Inc. Right Foot- Before & After Weight bearing- 2 weeks post-op After Before

70. Extra-Osseous TaloTarsal Stabilization with HyProCureTarsal Tunnel Decompression, Neurolysis of Posterior Tibial Nerve, Neurolysis of the Calcaneal Nerve, Neurolysis of the Lateral Plantar NerveNeurolysis of the Medial Plantar Nerve

71. Surgery TaloTarsal Stabilization with HyProCure Take about 10 minutes to perform Takes about 10 – 15 stents placements before you really get comfortable Tarsal Tunnel Decompression/Neurolysis Take about 20 min Should use loups Takes about 25 before you really feel comfortable in this area Take your time

72. Apply a tourniquet to the ankle I do not inflate the tourniquet unless there is excessive bleeding Use 10 cc’s of 1:1 mix of 0.5% marcaine with and without epi with 1 cc of dex. Phosphate Close skin only

73. The Results Depends on which fibers are being affected How damaged the nerves are How compliant the patients are How good of job YOU did on decompressing the nerves How much scar tissue the patient forms after surgery

74. Results- continued Pain is almost immediately alleviated. Restoration of sensation- will take the longest to return Results may be felt in the recovery room Or may takes months to years No matter, instead of the patient’s condition getting worse and worse, it will potentially get better and better.

75. Cross Over Effect This is real not imaginary. The damaged nerves of one foot affect the opposite foot. Scenarios: Good- Bad- Ugly-

76. Cross Over Effect - Good By decompressing one foot not only is there is improvement on that side there is also improvement in the contra-lateral limb. IF sensation/symptoms are restored to the contra-lateral limb there is not need for tarsal tunnel decompression or neurolysis of the nerves

77. Cross Over Effect - Bad Surgery to the foot yield minimal results with no change in the contra-lateral limb The opposite limb is the dominate nerve pathology and once that side is also decompressed there should be an additional effect on both feet. Must warn patients about this prior to surgery.

78. Cross Over Effect - Ugly Nerve decompressions are performed on both feet (one at a time) and no results are felt. Don’t take the patient’s word for it. Must perform nerve testing prior to surgery and routinely post-op. Their nerves may be so severely damaged that it was too late. No matter how severe I will still attempt. It just may takes years for the results to be felt.

79. Complications of Surgery Wound dehiscence Scar tissue formation Hematoma Infection Temporary increase in nerve symptoms ?% revision rate

80. Complications of:Supervised Neglect Decreased Activity Level Decreased metabolism Increased Weight (obesity) Diabetes Hypertension Arterial Disease Increased Nerve Pain Loss of Sensation Ulceration Bone infection Amputation Charcot’s Foot

81. Current 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

82. Nerve Pills: Neurontin, Lyrica, Cymbalta Mask the symptoms Do not help nerve repair Expensive Increased symptoms, increased dosage Side-effects Swelling/edema Blurred vision Drowsiness Fatigue/muscle weakness Muscle cramps Vomiting Constipation/Diarrhea Sexual dysfunction

83. Autonomic Neuropathy Manifests after years of peripheral nerve symptoms We really don’t know Why Who when Only get worse Really no help Orthostatic hypotension Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction

84. Comparison of Symptoms of Side effects from Nerve Pills and Autonomic Neuropathy. Orthostatic hypotension Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction Orthostatic hypotension Bladder dysfunction GI Problems Blurred vision Muscle weakness Sexual dysfunction

85. My Results Claim 80% effective within a year 20% will either just take > 1 year are the nerves are just too severely damaged.

86. Conclusion Doing nothing leads to progression Complications of proposed surgical treatment options have a better outcome than supervised neglect I hope that I have open some eyes so that we can change our thinking on this extremely serious condition

87. For Further Information/Training www.grahamiii.com

88. “Changing Lives, One Step at a Time” www.hyprocure.com View our on-line training www.hyprocuredoctors.com