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Friday, June 16, 2017

Nerve Pain: Email Advice

Dear Dr. Blake , Thank you so much for your blog I just wish that I had found it 7 months ago!. Can you please help me? I have been a labour and delivery nurse for 30 years. 12 hours days and nights on  my feet. Last year I broke 2 toes on my right foot and very stupidly continued to work . I could not wear a closed shoe so I foolishly wore flat shoes with no support and flip flops all summer.  7 months ago I started to wear my new supportive work shoes and a 7mm  lift. ( During the summer my osteopath diagnosed me with a 7mm leg length discrepancy as the cause of my lower SI joint pain). Within weeks I started to have pain under my 2nd Metatarsal on my left foot ( the foot I limped on for 4 months).
Dr Blake's comment: Is it also the foot with the lift? Very important because, if it is a heel lift it can transfer the weight to the metatarsals, and if it is full length it could be too stiff in that area. 

 I went to a podiatrist and he recommended a metatarsal pad. I tried to wear the metatarsal pad but it seemed to make things worse.
Dr Blake's comment: Met pads can make nerve pain in that area worse, and tendon pain worse, since those structures run back into your arch. Met pads normally help bone and joint pain unless too far forward. Did you try to move it around? 

 The pain soon was at the base of my 2nd and 3rd metatarsal . I went to physiotherapy and they diagnosed me with plantar fasciitis both feet ( no heal pain but pain under arches and below ball of feet worse on the left foot. Also they diagnosed me with possible capsulitis and neuroma. I ordered custom orthotics at this time. While waiting for the orthotics I continued to work. I started to experience intense burning and tingling shooting neuralgia. My feet were so painful the sheet could not touch them. 
Dr Blake's comment: The orthopedic problem had become neurologically over sensitive to protect itself. You now had the original problem, and nerve hypersensitivity, together. You have to take this very serious because it can lead to CRPS, so creating a consistent 0-2 pain level is crucial. 

I went back to the Podiatrist and he gave me a celestone cortisone injection between my 2nd and 3rd and 3rd and 4th metatarsal. After a couple weeks I started to get alot of relief in the burning and nerve pain the inflamation went down considerably. The cortisone allowed me to  receive physio therapy ( ultrasound and aggressive manipulation of my feet) I did all of the exercises I was given. 3 months later the symptoms returned with a vengence.
Dr Blake's comment: Unfortunately, it is common to have these long acting cortisone wear off and you need boosters. I tell my patients that they may need 3 total to address the nerve pain. While you are injecting a nerve, since it may wear off, consider oral nerve meds like Lyrica, topical Neuro-eze, neural flossing, ice pack 10 minutes twice daily. 

 I got another steriod injection this time Depro Medrol same locations.
Dr Blake's comment: Celestone is 6 mg per ml, whereas Depro is 20, 40 or 80 mg. It is very strong cortisone, as should not be used alot in the foot unless diluted. 

 After a very uncomfortable steriod flare 7 days later my foot started to settle down. I still suffer with the intense dull pain under my 2nd and 3rd metatarsal and my toes feel " out of joint" I can flex them but it feels swollen behind them and I cannot extend them without great ripping pain. I finally got an appointment with an orthopedic surgeon and he did xrays which showed no fractures, small heel spur. He diagnosed me with Tenosynovitis of the 2nd and 3rd metatarsals and plantar fasciitis . I agreed to PRP injections . I had a 2 week inflammatory response from those ( very painful) but my plantar fasciitis is 75% better  and the  Tenosynovitis is finnally settling down. I am icing several times a day. I was doing calf stretches but stretching irritated the tenosynovitis so I have stopped. The only advise I was given from this doctor was to rest and return in 5 weeks. I have been wearing a very flat firm slipper that my orthotic fits in I can't seem to wear my running shoes because they make my toes flex. It has been 3 weeks with very little ambulation in the day I am couch bound. I tried wearing a Budin Splint but it seamed to irritate the tenosynovitis on the toes. I plan to remain on the couch another 2 weeks then I see him again for the 2nd PRP injection if needed.

My questions are. 1) I think my orthotic is making it worse. When I walk I feel like I land right on the 2nd metarsal and when I tried a met pad it seem to cause the plantar ligament to pull on the capsule and the 2nd and 3rd metatarsals making the tenosynovitis worse. What do you recommend I wear on my feet? How long should I wait to try a met pad? How long should I wait to try the Budin splint again.
Dr Blake's comment: Orthotics are tricky for metatarsal issues since the end of the plastic is where you hurt. You can try a full length Sole (I prefer the red ones) with or without a loose fitting Budin Splint. Use a single loop Budin and open it up and place around the 2nd and 3rd toe, or the 3rd and 4th toes together. Yes, avoid met pads when there is nerve hypersensitivity. 

2) What types of shoes should I wear with this history.
Dr Blake's comment: Definitely try the Hoka One One Bondi or similiar to give you rocker. You may also need a Hike and Bike shoe for the rigidity right now.  How do you feel in a Danco clog, for cooking or short spurts?

3( Should I give up on the orthotic?. I pronate on both but much worse on my right foot . My arch is falling on the right. And the right foot is my good foot.
Dr Blake's comment: Give up on it right now, until we experiment with full length ones from Sole, Powersole, Lynco, etc. 

4) How long  should I remain off my foot? Should I completely immobalize my foot? How would you recommend I do this?
Dr Blake's comment: Nerves like warmth, motion, not prolonged stretching, non painful activities like walking. So, being immobilized is may help orthopedic injuries, the nerves hate it. I would have to know how you feel walking with crutches in a removable boot.

5)How will I know it is time to start restrengthening and returning to normal activities ie work?
Dr Blake's comment: Strengthening should be happening right now. This is usually organized by the PT. If you can not balance on one foot due to pain, you at least should be able to use a stationary bike with your weight in the heel for an hour a day. You should be doing a gym program for at least ankle strengthening, knee, hip, core, cardio, some upper extremity. Consider experiment with various beginner yoga poses or pilates exercises. Over the next month, every day find one exercise that does not hurt, and keep building.

6) I'm sure the 7mm lift in my right shoe has changed the weight distribution between my feet and has probably caused the perfect storm. I have been wearing the lift for 7 months now and it has been the answer for the S.I. joint pain I have had for 7 years ( GONE !!!) Should I have new orthotics made with no lift? I could get a separate lift made and add height a bit at a time.
Dr Blake's comment: The relief of the SI pain is pretty striking and emphasizes the need for the lift. I am glad the lift is not on your injured side. I love orthotics and lifts separate, so you can experiment. If the lift is only a heel lift, try to take that off and use a 1/8th inch full length lift (spenco insert) for the next month on the one side to see what happens. Hope all this helps some. I do want to say that lifts under your foot on one side have a very dramatic effect on the base of the spine. If I was treating you, I would order an MRI of the injured foot, and a Standing AP Pelvic xray with your 7 mm lift and orthotics to see how the spine, hips, and SI joints look. How level are they?


Please help me I am desperate to return to work and my life I love walking. I have been limping for 12 months now!
Karen

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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.