Sural Nerve Pain: Advice from an Email

10-27-10

Anonymous has left a new comment on your post "Morton's Neuromas: Which Shots to Get?":


Top of the right foot leading to the 3 toes-Sural nerve.
I have had the lydocaine shot (24 hours of relief!!), I just had a cortisone shot and now the pain is worse - much worse! I go back in 3 weeks and the next steps are the series of alcohol injections.
Are they painful?
I am already in considerable pain and do not relish additional pain. The cortisone shot was VERY painful.

Thank you So much!
 
Dear Anonymous,

      Sorry you are feeling so much worse from the cortisone shot. When nerves are irritated, any shot especially cortisone and alcohol, can be more irritating. Please find out if the shot was long or short acting cortisone. For sural nerve problems, with the diagnosis being made by the local anesthetic shot, I tend to treat topically only, although weekly local anesthetic shots to block the pain cycle is appropriate.

      For an anatomy lesson, the sural nerve runs along the outside of the 5th metatarsal and 5th toe. From your description, the nerve involved must be the intermediate dorsal cutaneous off the superficial peroneal nerve, or referred pain from the L5 nerve root in the low back.  Both of these nerve problems cause pain and/or numbness on the top of the foot into the 2nd, 3rd, and 4th toes (with occasionally part of the 5th). So, in your upcoming workup, you need to correctly identify the nerve involved, and see if it is referred pain from the back. You do not have to have any back pain for the problem to be arising from your back.        

      I have not used alcohol shots for sural nerve, or any other top of the foot nerve, and personally hate to give cortisone or alcohol in such a superficial area. It is not saying it is bad since I have no experience, I just feel uncomfortable. I would consult with Dr Gary Dockery in the Seattle area who has done these alcohol shots the most. Perhaps, if they are done, the concentration may be much less than the normal 4 to 6%.

      However, before I would do anything other than further local anesthetic injections which could be done weekly or twice a week,  I would use three times daily topical OTC NeuroEze (in previous posts), or a topical compound medication with Ketamine/Gabapentin/Lidoderm mixture. You will have to have a podiatrist, physiatrist, neurologist, or pain specialist prescribe. You can also get an RX for Lidoderm Patches which you apply for 12 hours continuously.  The prescription would be for several months. You may have to go into a removable boot if you can not take any shoe pressure. You need to eliminate any day to day nerve irritation to let the nerve calm down. Warm water soaks 3 times daily for 10-15 minutes with gentle massage should help calm down the nerve. Nerves tend to hate ice, and you want to avoid anything that stimulates the pain cycle. Your doctor involved may recommend some type of pain medication to help you, not anti-inflammatory medication which does not work at the nerve layer of pain. If you can take Extra-Strength Tylenol, start there. Advil and Aleve normally help with inflammatory pain, not nerve pain.

     So, while you are trying to identify the correct nerve involved, decide if it is coming from your back, start treatments to calm down the nerve, hopefully you won't need the alcohol shots anyway. Give me some feedback after you have initiated some of these. Rich Blake

See other posts on nerve pain.
http://www.drblakeshealingsole.com/search/label/Nerve%20Pain