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Tuesday, April 3, 2018

Tarsal Tunnel: Basic Thoughts for Treatment

Hi Dr. Blake,

It's been a while since I have been to see you. I hope you are well.

When I was in your office last I was dealing with tarsal tunnel syndrome, and I solved it with repeated acupuncture. However, the acupuncture does not seem to be doing the trick anymore, and it has become too painful for me to run. Shall I come back to visit you or do you know of a specialist that might be able to help me?

Thanks so much for your help.

Dr. Blake's response: 

 I will be happy to re-evaluate. I am including a blog post I wrote to see if anything can be addressed. 


The following is a short piece from my book "Secrets to Keep Moving: A Guide from a Podiatrist"

1. Introduction to Nerve Pain Treatment

First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves you should be addressing 4 areas---mechanics (what stresses the nerve and what protects the nerve), anti-inflammatory (in general, contrast bathing or warm water soaking is better than ice, along with oral & topical anti-inflammatory meds), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc).

          Therefore, the standards of care I use for nerve pain in the foot and ankle involve the following:

1.      Mechanics
2.      Anti-Inflammatory
3.      Nerve Desensitization
4.      Diagnostics

          It is the 4 areas that form the basics of each visit decision making. The KISS (keep it simple stupid) principle does apply based on the level of pain and disability being produced.

Mechanics

          The 3 aspects of mechanics for nerve pain on the foot/ankle (and other parts of the lower extremity) are:

1.      Recognizing if motions or positions that the patient places themselves in can
        stress the sciatic nerve and its branches.
2.      Creating protected weight bearing environment so that every step does not create      
        pain. This is done with inserts, braces, pads, shoe gear, etc.
3.      Protecting a sore spot when shoe pressure causes pain with pads, sleeves,  
        skipping laces, etc.

Anti-Inflammatory:

         Nerve pain may be neuropathic (produced by the nerve itself), inflammatory (produced by inflammation around the nerve), or a combination. When treating nerves, various anti-inflammatory measures should be tried to see if there is a response. Ice, one of the mainstays of anti-inflammation can be very irritative to nerves and may have to be limited to 5 minutes. Massage can also have the same helpful or irritating effect. So, anti-inflammatory treatments of nerves can be a little more tricky than treating tendinitis. Contrast bathing, warm socks, oral meds, topical patches may be helpful.

Nerve Desensitization:

          Nerve pain can spiral out of control easily, so doing treatment to desensitize the nerve from the start can be very helpful. I typically start with an OTC medicine called Neuro-Eze (product online) and Neural Flossing or Gliding (both done 3 times daily). Oral medicines are started only in the evening, and started at low doses, like Lyrica, Neurontin etc. But, many of my patients get wonderful help with Acupuncture, skin rolling (common for fibromyalgia), or Compounding topical medications.

Diagnostics:
From the first visit, I continue to ask do I need more information. Low Back Evaluations, MRIs, lab values, Nerve Conductions Tests & Diagnostic Injections can all play a vital role.   

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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.