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Thursday, November 7, 2013

Tarsal Tunnel Syndrome after Big Toe Joint Injury: Email Advice

Dear Dr. Blake,

I have been dealing with sharp/shooting pain and tingling in my foot since January (I was originally diagnosed and treated for stress reactions in the metatarsals, then sesamoiditis, and for the past few months, tarsal tunnel.)  The tarsal tunnel syndrome was confirmed with a NCV/EMG test, however, despite 3 months of physical therapy, surgical shoe bracing, and a 200mg daily dose of Lyrica, the pain, tingling, and numbness in my foot and ankle have grown worse.  I had a recent MRI (I attached some images.).  Do you see anything abnormal which could be contributing to the problem?  I am about to get a second opinion for surgery.  Do you have any other suggestions?

Thank you,
Cindy (name changed)

Dr Blake's response (after the patient sent FedEx the CD with images and reports):

Hey Cindy,

 I am so sorry about your situation. Hopefully, you can get this resolved without surgery. From what I gather from looking at your MRIs and reports, you injured the tibial sesamoid under the big toe joint 10 months plus ago. This caused swelling in the big toe joint, and this still exists to be worked on, since it can continue to be a trigger for nerve pain. I think the big toe joint injury still has a little healing to go, and you must daily try to protect with dancer's pads/orthotics, reduce the inflammation, and allow weight bearing since you are showing signs of some demineralization in that area. Make sure your Calcium and Vit D3 are good--typically 1500 mg calcium and 1000 units Vit D3 daily. 

     The nerve pain can be from many sources and normally is a combination of things. The tendon that goes under the big toe joint was still inflamed back in the ankle and probably has caused pressure on the tarsal tunnel nerves. Any limping that causes you to supinate (walk on the outside of your foot) can also be an irritant to the tarsal tunnel. You have some low back dysfunction, even if mild, but can still cause some hypersensitivity to the nervous system. L5 nerve root affects many nerves under the middle of your foot. The removable boot, even if you use an EvenUp (hopefully you did!!) can tweak the low back or hyper-extend the knee causing neural tension.

     All this being said, you have many reasons, non-serious that could have (and still are) stirred up your nervous system. You have had all the right tests, but now you need to find someone to calm down your nervous system. Addressing the possible triggers are important, so decreasing inflammation in the big toe joint makes sense, making sure you are not walking to the outside of your foot, making sure you are not hyper-extending your knee, making sure your gait is centered (not dominant to one side which is always bad from the spine), and perfecting all the ways to calm down the nervous hypersensitivity. I have many posts on my blog that can help you, but you need someone in pain management that can help with Rxs,etc. Medicine seems good at evaluating and treating damaged nerves, not hypersensitive nerves. 

     To help you get started, work daily icing and contrast bathing for the big toe joint. Weight bear to tolerance if possible gradually improving duration. See a physical therapist to find out how to protect the sciatic nerve, and keep your spine neutral when you do activities, and outline a plan to increase activities. You might need an epidural injection to calm down the nervous system, and if you have any sympathetic signs (skin discoloration, changes in sweating, etc), also need a sympathetic block. I had to have both after a back injury, but they were done at the same time. Treatment to the foot/ankle has to be gentle due to the nerve hypersensitivity without injections (unless you are calmed down). Deep massage should also be avoided. You need to be doing non painful strengthening of your foot, and typically swimming or stationary bike are used for cardio (this is where the physical therapist can help). Hypersensitive nerves love gentle motion, heat, gentle massage. Learn what is neural flossing so that someone can show you if appropriate. Easy to do multiple times a day. 

     In terms of medicine, stay on 200 mg Lyrica right now, and add Cymbalta or Elavil at bedtime. These changes are common to begin to get ahead of the symptoms and necessary since you are increasing in symptoms. Have a RX for Lidoderm patches and a compounding medication for nerve pain (you could start using the OTC Neuro-Eze and find where you can massage without increasing pain). I have patients who can not massage due to the pain, but a compounding spray is given which helps.

     There are 2 types of physical therapy--musculo-skeletal and neurological. You need neuro based physical therapy right now. There is a daily, sometimes hourly, distinction to be learned about Honoring your Pain vs Working Through your Pain. It is an important skill to learn.

     Cindy, I hope this helps you somewhat. Keep me in the loop. Rich

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Thank you very much for leaving a comment. Due to my time restraints, some comments may not be answered.I will answer questions that I feel will help the community as a whole.. I can only answer medical questions in a general form. No specific answers can be given. Please consult a podiatrist, therapist, orthopedist, or sports medicine physician in your area for specific questions.