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Tuesday, September 30, 2014

Calf Pain with other symptoms: Email Advice and Response to Neural Flossing

Dear Dr. Blake,

     I have been studying your blog for a few weeks now and enjoying your expertise and caring manner.  I wish you could be my Dr,  I am looking for advice on how to direct my podiatrist appointment in 9 days.  I will try to make this to the point.  10 yrs ago I stepped down on a rock while saving my son from an active dog and got a stress fracture on my sesamoid

    Wore a boot and orthotics made by podiatrist. In the last 6 months I began having knee/calf pain and my sesamoid toe - the big one - was acting up.  Podiatrist took xray and didn't see fracture and added a dancer pad to my orthotics.  The sesamoid started feeling better, but I still had the mild calf/knee pain and the ball and heel of my foot hurt when I walked barefoot.  The pain was bothering me enough to take ibuprofen. 

    5 weeks ago I reached up in a standing position and I couldn't bear weight on my foot due to extreme calf pain.  I was unable to stand on my tippy toes.  Podiatrist sent me home with 1500mg nabumetone and said to come back in 2 weeks diagnosing me with tarsal tunnel after pushing on foot with his hand to find pain points.  I began physical therapy 2x a week.  

    Eventually I was able to walk but not without pain.  The med prescribed made me tired and my belly hurt so I took ibuprofen instead.  At my 2 week appt with podiatrist he offered me cortisone telling me it was more diagnostic to find out where to operate or a cam walking boot.  I chose the boot - that was 3 weeks ago.  Last week I took off 5 days off my part time custodian job, took the med prescribed and layed low icing and resting.  Felt much improvement, but still unable to walk barefoot due to heel/pad/calf pain. 

    Back to my 2nd day of work wearing my boot and the calf pain is getting worse.  I did get a 2nd opinion last week by an orthopedist and he acted as if I wasn't telling the truth about my pain.  I am looking for help with my next podiatrist appt.  I understand that sesamoid can cause other issues - I also pinched a sciatic nerve on same side of body after recent sesamoid pain.  I know that cortisone will be my next option and it scares me. I am not confident about the diagnosis of tarsal tunnel.  The Dr. said he could do other tests but they wouldn't tell him much. 

    Am I correct that if I get injected in the wrong spot that I could have other problems?  I am somewhat mobile now and have no interest in making the problem worse.  I understand that cortisone is a band aid to the issue and the shot itself truly freaks me out.  Would you recommend an mri or any other tests to make my diagnosis more concrete?  If I truly have tarsal tunnel I believe the Dr. wants to do surgery and resources online say I have a 50/50 chance of being better.  The recovery of surgery seems miserable and I really don't want to be immobile.  I have already given up the gym I went to 4x a week.  When I spoke with orthopedist about the sesamoid/sciatice nerve issue playing a part in my current issues I got a blank look.  I want to go to podiatrist armed with information to help me make the best decision for myself.  Can you help me?

Regards,
Toni (name changed)


Toni,
      I am out of the office until 9/29 and will try to get back to you that week. Rich

Hi Dr. Blake,

     I got a 3rd opinion yesterday and he thinks baxters neuritis and planters fascitis.  He listened to my ideas of right side issues and I am having an emg.  I believe this podiatrist will help me get to the issue of my pain.  Writing to you and reading your blog has helped  get my brain in order to advocate for a correct diagnosis.  Thank you for being there to help me get this into words.  I will follow up with you once I get emg results.  
Enjoy your time out of the office


Hi Dr. Blake,
    Thank you so much for your blog.  It has empowered me to find a doctor who takes my pain seriously.  I had an emg done and there are no nerve issues.  I've been diagnosed with plantar fascitis and peroneus longus tendonitis. After reading your information on these issues it makes sense.  I believe I have found the right diagnosis.  I am off work for 2 weeks and now have a night splint along with the cam walker.  Dr. also prescribed me a cream compound with lots of meds to help with pain and blood flow.  I am also going to continue with physical therapy.  Unless you feel the need to respond I'm ok with studying your blog on these issues and taking your advice.  I appreciate your information so much and hopefully I will be pain free soon.  Take care.

Dr Blake's response finally: 

     Toni, thank you. I am back from the Greek Isles (someone had to go) celebrating my wife's big #__ birthday (intentionally left out number). I am so happy you found someone to listen. Tarsal Tunnel diagnosis is so difficult to make that considering injections and surgery for this needs to be very well thought out, with numerous opinions. With your history of sciatica, and the nerve hypersensitivity that can linger, you can have symptoms all along the course of the nerve leading to many mistaken diagnoses---from metatarsal pain, to arch pain, to heel pain, to ankle pain, to calf pain, to pain in back of the knee or thigh or butt. Changes in your gait, especially over supinating (or rolling to the outside of your foot), can trigger sciatica. This nerve hypersensitivity does not mean nerve damage, and that means the nerve testing (conduction or emg studies) can be negative. This severe calf pain that you had is typically only produced by nerve pain or blood clots, so if the calf pain gets bad again have a doppler ultrasound of your calf to rule out DVT (deep vein thrombosis). Your treatment right now makes sense (activity modification, protected weight bearing, and physical therapy). Eliminate all that sets off any pain. Do neural flossing from my blog for several days to see what symptoms it helps or irritates, but hopefully it is very relaxing to the sciatic nerve. When you stretch the calf, and you should 3 times a day, always keep your knee slightly bent to protect the sciatic nerve. As the pain calms down, all of the secondary symptoms should go first, with the pain from the main injury lingering. Daily keep track of what hurts (say at the end of the day) that day. You hopefully will see a pattern. The problem you face, when you have many symptoms, is that the docs and physical therapists can spend a lot of time treating secondary symptoms, and lose track of what is important to treat consistently. I sure hope this helps somewhat and thanks for all your kind words. Rich

Patient Response:
     Dr. Blake,
Thank you so much for taking the time to help me with my issues.  The neural flossing helped tremendously! The first time I did it my hip cracked every time and I knew we were onto something.  After first day the throbbing in my foot/calf stopped and my hip hurt like crazy.  After 4 days I was able to walk more comfortably and I only have pain in my heel when I walk barefoot.  I saw a chiropractor and he found issues with my L5 and other things.  Today I am returning to work!  If I hadn't done the exercise I would have been strongly been considering cortisone in my foot due to being tired of the pain.   I believe you helped me avoid the unneeded shot and I am grateful.  I have an appointment with my podiatrist and I'm not sure I need to go.  I would love to share this information with him, but not sure it's worth the office visit.  
You are a good man for sharing your knowledge with the world.  I will find a way to pay it forward.  Thank you so much!

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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.