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Thursday, April 5, 2018

Complex Foot Injury: CRPS??


Dear Dr. Blake,

     The gentleman from Mountain Family Products referred me to you because my podiatrist recommended a bone stimulator.  I didn't want to wait for the insurance to pay some time next month because I am concerned about my work and getting healed in a timely manner. 
   
   On February 2, I stubbed my toe on the way to the airport for a business trip in Europe.  I was sort of healing the month of February when I re-injured it about 3 weeks ago and now the pain is through the roof.  Nothing seems to help.  I went to my osteopath first and he told me to get metal inserts for my tennis shoes.  That didn't help.  Then he did a cortisone shot on March 12 that lasted about 4 days and the pain came back. 
Dr. Blake's comment: This is the first clue about what will help. We know the pain can be eliminated by the shot, even if temporary. What did he inject? The MRI revealed bone edema at the 4th metatarsal. Did you stub the 4th toe? 

  Then he did a nerve block and it didn't help.  
Dr. Blake's comment: Was the nerve block in the same spot? 

     Finally, yesterday I saw a podiatrist who gave me an insert for my shoe, told me to take Calcium, Mag, D and some neuro vitamins like Metanx - which I happen to have.  I have a scooter I am using since last Friday to keep as much weight as possible off the foot.  I tried on a boot and it was too painful. The doctor also recommended a bone stimulator and using some ice packs no more than several times a day for 20 minutes or less.  He also gave me tramadol which didn't help.  I tried ketamine cream and that didn't help.  I started something called Dr. Christopher's tissue and bone ointment to see if that will help.

     I saw that Dr. Axe mentioned the following:  L-lysine, bromeliad, vitamin k as supplements for bone bruises.
Dr. Blake's comment: There are 3 types of pain: mechanical (just as a break), inflammatory due to the healing response, and neuropathic due to nerve injury or nerve protection (hypersensitivity). You are succeeding in mechanical means to lower the pain, some inflammatory should be helpful. It does not sound like neurological treatments like ketamine help topically, but you must have some neurological component to your injury. You may want to try oral pills like Gabapentin. 

     I have an autoimmune neuropathy from a toxic exposure last year.  My feet already burn and my nerves are hyper anyway.  The pain is very agitating for me because the burning isn't under control.  My neurologist is trying to get IVIG infusions for me.  The pain from the foot is radiating all over my foot and up my leg.  I think part of that is the way I have been walking - or limping around.  My feet have been burning since last October and sometimes I don't know if it is the SFN or the foot.
Dr. Blake's comment: So, have they worked you up for Complex Regional Pain Syndrome? You are set up for it with the nerve issue already. You create a 0-2 pain level with your scooter, you may need Sympathetic Blocks, IV Ketamine, or Calmare Pain Therapy. You may just need Lyrica or some cocktail that cools the nerves down. How does it feel to rub in creams like Ketamine? 

I guess I am just wondering if there is anything on your blog or on the internet that may help me in my healing process.
Dr. Blake's comment: Typically, while docs work on the nerves, PTs and acupuncturists help with the pain, and deciding what you can and can not do. See my blog on CRPS to see if that makes sense. See a neurologist if it does. Try to find a PT who understands CRPS because it is important to honor the pain at times and push through the pain at times. 

I am enclosing the notes from the MRI. Does not say much!!

Thank you in advance for any direction.

Kindest regards

And the patient's response:

Dear Dr. Blake,

I posted my responses to your questions on the blog.  Thank you very much for your responses and insight.    I am going to have a ketamine infusion on Monday.  My neurologist says one infusion each month is enough so I will see how I tolerate it.  My foot was healing ok until I decided to do a little dance to make myself happy - now I wish I had just stayed morose... Anyway, I am doing meditation, self-hypnosis, 2000 mg of C divided during the day, I have glia modulators - LDN and Nortriptilyne.  I am weaning my self off the lamotrigine.  I am hoping to get a trial of IVIG in the near future.   I went ahead and bought the bone stimulator and it will arrive tomorrow.  I couldn't wait until the middle of next month when the insurance will kick in.

I am going to try the nerve flossing and I have a mirror set up for the mirror therapy (I saw it on youtube)  I also called my PT who will call me back next week.

I am trying to cover all my bases because I have a very real possibility of losing my job since the autoimmune neuropathy has been going on for 8 months now.

Anyway, thank you again for all your help.  Greatly appreciated.

Dr. Blake's response: I am so happy and great faith you will get the nerves calmed down. Go to NOI group website and order their extremity cards. It will make sense when you see them. You can get sublingual Ketamine for flare-ups. Let me know 2 weeks after the Ketamine infusion, and for our readers, get as much information on exactly what the infusion center will do: dosage, mixture, time of drip, etc. Good luck Rich

Another Response from the patient:

Another question...

How often can I use the stimulator?  My doctor suggested 20 minutes once a day and any more than that would be a waste.  Ross - at mountain family - mentioned that he heard of some patients using it 20 minutes with a 12-hour window between treatments.

Thank you

Dr. Blake's comment: Yes, I would do the 20 minutes twice a day for the first 4 months, and then you can cut it down to once a day. 

The Response from the patient:

Rich

Thank you for your message and the information.   I had the ketamine infusion and it was one of the worst experiences of my life.  I will go back and find out the specifics.  I had horrible hallucinations and was very nauseous.  I could hear the nurses laughing and talking the whole time.  It didn't help at all and in fact, I felt worse probably because it traumatized me.   I think that it is best to go to a clinic that specializes in ketamine.  I haven't given up on it but I think that it's important to find the right place.

I am going back to the podiatrist tomorrow and I found a pain management physician who knows about CRPS and she actually had an opening on Thursday this week.  I am going to order the R-alpha lipoic acid and the NAC to get started on them.  Unfortunately, I will have to cancel a very important business trip and I am nervous that will cost me my job.

I will look into ordering the cards.

Thank you

Dr. Blake's comment: I am so sorry for your bad experience. Infusion Centers in general are peaceful, calm, no noise, so you were definitely not in the right place. Yes, you need one familiar with the nuisances of Ketamine. I have attached a reference for dosing for you. Please find out what the dose they gave you. You can see from the article that the range is from 1 to 4.5 mg ketamine/kg of your weight. It would be important to know if you got minimum or maximum dose as your loading dose based on your side-effects. Was there someone there with you to hold your hand? Important. Were the lights dim in the room? Important. Quiet!! Very Important. 
https://reference.medscape.com/drug/ketalar-ketamine-343099

The patient's later response:

Hi Dr Blake,

I wanted to give you and your blog readers an update...

I was worried after fracturing my toe (4th toe on left foot) I was developing CRPS because I have other nerve issues.  I fractured my toe on Feb 2 and the pain just got worse.  My foot turned ice cold blue and was like that for over a week plus my fracture wasn't healing and I was having shooting nerve pain/burning in my foot.  I am wearing a boot and have a scooter.  I did the following to try to heal my foot (which I found some of it on the blog from another reader):

  • Went to a new anesthesiologist who just moved here from Cleveland Clinic and specializes in CRPS.  I was lucky to get a next day appt with her.  She was very nice and felt that it wasn't CRPS.  She did give me Cymbalta - which I didn't take since I am sensitive to medication.
  • Bought a used bone stimulator and used it twice a day (based on recommendations from several doctors - including Dr Blake)
  • Light massaging to increase the blood flow
  • Putting leg up when sitting or lying down
  • Started taking (all of these without fillers) each day:
    • 1200 mg of R-Alpha lipoic acid
    • 1200 mg of NAC
    • 2000 mg of vitamin C (powder to mix in water with cranberry concentrate)
    • 600 mg of Calcium Citrate (powder to mix in water with cranberry concentrate)
    • 5000 mg of vitamin D
    • Magnesium citrate
  • I am taking some herbs as well
    • Stinging nettle tincture (without alcohol)
    • Horsetail (without alcohol)
    • Comfrey tincture rubbing on skin over fracture and applying DMSO on top for better absorption.  I purchased Heiltrophen on Amazon - the bottle and dropper are glass which is important because DMSO absorbs everything.  I applied with clean hands and washed them afterwards without soap.
    • I tried Dr Christopher's Syrup and Ointment for bone and tissue repair a friend recommended.  Tastes and smells awful.  Lots of stars on Amazon but I couldn't stand it to take it consistently.
  • Mirroring 
    • My friend let me borrow a mirror so I am doing some mirroring exercises I found on youtube.
  • Went to Orthopedic surgeon (I wanted a second opinion in addition to my very good podiatrist just because the foot wasn't healing).  I was lucky that the orthopedic doctor for the feet of the US ski team had an appt.  Really nice guy - he just confirmed what my podiatrist had recommended)  He said I needed to be off the foot for 6 weeks and gave me a clearance for work.
So I am happy to say after 6 weeks on my protocol,  that the pain is almost gone from my foot.  I don't have the shooting nerve pain in my big toe and the burning is less.  I am able to walk very short distances without the boot.  It isn't keeping me up at night.  It looks like I am on a positive trajectory.  I think it will still be a while before I really feel comfortable walking longer distances and doing my normal routine but at least, it is getting better.

Thank you so much Dr Blake for your support and help.  

1 comment:

  1. Dear Dr Blake,
    Thank you so much for your response. Very kind of you to take the time. Please see my answers below...


    What did he inject? Cortisone

    The MRI revealed bone edema at the 4th metatarsal. Did you stub the 4th toe? Yes

    Was the nerve block in the same spot? No, he did the nerve block on my lower ankle with a series of lidocaine injections down my leg (4 injections)

    You may want to try oral pills like Gabapentin. I tried before for the nerve issue and I couldn't tolerate it. I am currently on lamotrigine 50 mg and nortriptolyne 10 mg and LDN 4.5 mg plus the supplements of Calcium, Mag, VitC, B vitamins, omega 3 etc... I am very sensitive to medicine. The podiatrist gave me some tramadol 50 mg but it did nothing so he told me to go up to 100 mg

    So, have they worked you up for Complex Regional Pain Syndrome? No but the podiatrist is concerned about it and wants to see me back in two weeks. I mentioned it to my neurologist. I just put a call into my pt who I think is familiar with this issue because he also does some POTS work and other nerve issues.


    How does it feel to rub in creams like Ketamine? Ok, but the compounded ketamine/gabapentin/bactim/lidocaine cream didn't really help. On Monday, my neurologist has scheduled me for Ketamine iv

    ReplyDelete

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.