Eric H. Williams, MD

Eric H. Williams, MD, graduated from Johns Hopkins School of Medicine in 1999 after receiving his undergraduate degree in Biology from Swarthmore College in the suburbs of Philadelphia, Pennsylvania. Dr. Williams completed his General Surgery Residency at Vanderbilt University Medical Center in Nashville, Tennessee in 2004. He then completed his Plastic Surgery Residency at the University of Alabama in Birmingham in June of 2006. Dr. Williams then completed another full year of fellowship training in Peripheral Nerve Surgery with Dr. A. Lee Dellon, a world-renowned specialist in peripheral nerve surgery, in 2007.

Dr. Williams is board-certified in Plastic and Reconstructive Surgery. After his fellowship, he was employed by The Dellon Institute for Peripheral Nerve Surgery for two additional years until he became a full partner at The Dellon Institute in Baltimore, Maryland, in 2010, dedicating the majority of his time to caring for nerve-injured patients.

His focus since 2007 has been centered on the surgical care and rehabilitation of lower extremity and upper extremity complex peripheral nerve syndromes with an emphasis in nerve injury, entrapment, and chronic regional pain syndromes, and diabetic peripheral neuropathy.   Other areas of interest and expertise include groin pain, knee pain after knee replacement, intercostal nerve injury, and migraine headaches, piriformis syndrome, and low back pain due to superior cluneal nerve entrapment.

He has independently developed procedures to improve the sensation, pain, and muscle function in the lower extremity, and has been part of a team that has helped describe many other advancements in peripheral nerve surgery and peripheral nerve imaging.  He has written and is a co-author of many publications in the field.

While working in private practice, he is an Assistant Professor of Plastic and Reconstructive Surgery at Johns Hopkins University Medical Center in Baltimore, Maryland.

00:00 – Introduction

• Dr. Barrett introduces Dr. Eric Williams, plastic surgeon specializing in peripheral nerve surgery
• Focus on tibial nerve entrapments, particularly proximal tibial nerve at the soleus sling level
• Dr. Williams published groundbreaking papers (2009-2012) on this relatively undiscovered nerve entrapment

01:19 – Opening Discussion

• Welcome and context: Follow-up to previous episode on CRPS pediatric patient
• Topic focus: Soleus sling syndrome

02:06 – Discovery of Soleus Sling Syndrome

• Discussion of how this was “rediscovered” rather than newly discovered
• One paper from 1981 existed, but condition was largely ignored
• Discovery came from combination of need, epiphany, and luck
• Question raised: Why wasn’t proximal tibial nerve studied more?

05:27 – Historical Context

• Dr. Barrett credits Dr. Williams’ 2009 work with Lee Dellon and others
• Cadaver lab studies brought this condition back into recognition
• Analogy to upper extremity: carpal tunnel vs. proximal median nerve entrapment

07:21 – The Epiphany Moment

• Dr. Williams describes looking at anatomy textbook (Grant’s or Gray’s)
• Noticed forearm diagram looked identical to lower leg anatomy
• The tibial nerve through soleus sling resembled proximal median nerve compression
• Connection made with Jay Erickson’s work on proximal median nerve

10:48 – Exertional Compartment Syndrome Connection

• Family friend Dr. Don Detmer (vascular surgeon at University of Virginia) specialized in chronic exertional compartment syndrome
• Explanation of how compartment syndrome develops
• Traditional compartment releases done mid-leg vs. proximal release at soleus sling
• Key insight: Venous outflow obstruction more important than previously recognized

17:08 – Clinical Examination Techniques

Two Key Exam Findings:

1. Muscle weakness: Flexor hallucis longus (big toe flexion)
2. “Open eyeball sign”: Palpation approximately 9 cm below knee in popliteal fossa causes dramatic pain response

18:02 – Physical Examination Details

• Location: Hand’s breadth below knee
• Patient reaction: “Eyeballs pop open” and “jump off table”
• If no strong reaction, diagnosis questionable

22:25 – Additional Clinical Signs

• Open eyeball sign specifically for soleus sling syndrome
• Comparison to popliteal artery entrapment syndrome
• Importance of bilateral comparison

24:52 – Muscle Testing Discussion

• Posterior tibialis weakness evaluation
• Toe raise provocation test against wall
• Discussion of subclinical nerve entrapments

26:56 – Post-Phlebitic Pain Syndrome

• Patients with history of DVT (deep venous thrombosis)
• Chronic pain after DVT resolution
• Soleus sling release can help this patient population

29:04 – Combined Nerve Entrapments (2012 Paper)

• Discussion of dual entrapments: common peroneal AND tibial nerve
• Typically associated with lower extremity trauma
• Patients with symptoms in both dorsum and sole of foot

33:27 – Additional Entrapment Sites

• Deep posterior distal compartment
• Area 12 cm proximal to tarsal tunnel
• Importance of examining entire tibial nerve course

37:07 – Deep Posterior Compartments

• Distinction between proximal and distal deep posterior compartments
• Can be completely separate
• Release of both may be necessary

38:01 – Physical Exam Emphasis

• Following entire tibial nerve essential
• Patients usually indicate where entrapment is located
• Two main sites: tarsal tunnel and soleus sling

40:05 – Surgical Approaches

Three approaches discussed:

1. Medial approach (Dr. Williams’ preference)
   • Most straightforward
   • Heals well
   • Must be careful with saphenous nerve
2. Posterior approach
   • More complications possible
   • Risk to sural nerve
   • Motor branches to gastrocnemius vulnerable
   • Better for complex cases or redo surgery
3. Lateral approach (mentioned by Dr. Ellison)
   • Combined with common fibular release
   • Only 2 cm from common fibular nerve

42:30 – Surgical Technique Details

• Medial approach technique
• Plantaris tendon removal consideration
• Careful fascial release with blunt dissection

45:55 – Dr. Ellison’s Lateral Approach

• Surprise, Arizona surgeon’s technique
• Combined procedures from single lateral incision
• Interesting finding: Many patients don’t need subsequent tarsal tunnel release

47:26 – Treatment Decision Making

• “Double crush” phenomenon discussion
• Patient involvement in decision crucial
• Factors: trauma location, travel distance, patient preference
• Individualized approach essential

50:06 – Art vs. Science of Treatment

• Cannot fit patients into algorithms
• Individual context matters
• Peripheral nerve surgery complexity beyond technical skill

52:53 – Patient Psychology

• Assessing patient expectations critical
• Realistic vs. unrealistic expectations
• Central nervous system changes after nerve injury

54:36 – Contact Information

• Website: DrEricWilliams.com
• Practice: Dellon Institute for Peripheral Nerve Surgery
• Location: Baltimore and Towson, Maryland

55:45 – Revision Tarsal Tunnel Surgery

• Two cases discussed from that week
• Importance of checking for proximal tibial nerve in failed tarsal tunnel
• Success rates: 50% overall, 92% in trauma patients, 30% in diabetic neuropathy

58:40 – Madrid Study Discussion

• 50 cases with pre/post EMG testing
• 100% showed improved nerve function
• Only 70% had pain relief
• Demonstrates centralization of pain independent of nerve function

1:00:21 – Closing Remarks

• Acknowledgment that not all cases succeed
• Importance of continued work in this field

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