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Tuesday, October 15, 2013

Foot Injury with Nerve Pain: Email Advice

Dr. Blake,
I found your blog this morning as a started in on two weeks of trying to completely not use my foot.  My email will be long as has been this nightmare Odessa.  I pray you can shed some light on this matter.

On July 29 I slipped on a wet spot in a store while wearing high stiff bottomed heels.   I slid gently into the slip and ended up on one knee with my left foot behind me as though kneeling to ask someone to marry me, plus perhaps a little more stretched out.  I got up and all seemed fine.  I went for my 3 mile walk the next 3 days with no pain.  On the 4th day I woke up with pain in the ball of my foot underneath the big toe and it became slightly swollen.  I could not pull my big toe back without sending a sharp pain down the foot.
Dr Blake's comment: This is the first sign of a small injury. The longer it is between injury and symptoms, the more minor the problem. I am looking for signs of hope for you. 

I went to the podiatrist and she did X-rays to see if the sesamoids were fractured and wrapped the foot.  That night the wrapping made the medial arch cry out in pain.  I took the wrapping off.
Dr Blake's comment: I make this mistake all the time since it is hard to know actually how tight to do in face of swelling that needs room to spread. The pain is not a sign of worse problems. 

The X-rays showed no fracture but a bipartite sesamoid and I only have one in each foot.
Dr Blake's comment: Bipartite Sesamoids are weaker than normal sesamoids, and thus, can get injured easier. It is usually a bad sign if x rays show bipartite sesamoids and point to an injured connection between the two pieces (weakest link in the chain). 

I continued to walk on it, limping and landing on the foot flat not really bending the joint under the ball.  A week later after Ice and Motrin I went back to the Dr and the swelling was down and the Doc said I was getting better and gave me hard orthotics with a high arch.  They made the foot hurt like heck again in the medial arch.  I still could not walk right.  My big toe did not work on push off and I could not make the foot walk. 

Dr Blake's comment: Orthotics should change function, off weight areas, feel borderline obnoxious, but never hurt. It is imperative to get them fixed by analyzing what is wrong and fix that (for example lower the arch in your case). 

 She did an MRI that only showed some mild edema by flexor abductor.  They could not visualize the sesamoids which kind of defeated the whole purpose.
Dr Blake's comment: This is impossible. Did you see the MRI? Can you look at the CD and send me images of the views that I normally show on my sesamoid posts. Something is rotten in Denmark!!

  She was flustered that I could not walk and threw me in a cam walker and thought maybe I tweaked a nerve and offered a cortisone shot.  I refused as she seemed to be guessing ( she would have put it in the tarsal tunnel).  Once again I only wore the boot one day and that night I had the worst deep aching pain in the center of my arch.
Dr Blake's comment: An injury causes pain. But, living with that injury, causes secondary pains from nerve protection, muscle/tendon favoring/splinting, inflammation not being controlled right. You need to do what you can to create a pain free environment while you are working on a specific diagnosis. Without a diagnosis, your treatment is too much guess work. You may need 2nd opinions, other tests, etc. 

Next I went to an orthopedic foot and ankle doc at the HSS.  He thought the nerve was getting trapped or irritated under the Knot of Henry. 
Dr Blake's comment: The Knot is back in the arch. The original injury is the ball of the foot. Do not lose focus on the ball of the foot, for the other pain is secondary. I like the idea of PT to reduce inflammation only. What about a repeat MRI to find those sesamoids, or a nerve conduction test if the nerve are being suspected. The same doc that does nerve tests are typically the best at calming nerves down with topicals and oral meds. 

 He wanted to do a diagnostic lidocaine shot but I refused.  He said PT with only modalities to bring down inflammation- come back in two weeks if not better and get a cortisone shot. The most tender point was right at the knot of Henry and that night after he palpitated  it I had the worst deep nerve pain.  When I got up I had pins and needles(. Which is the only time I have had this). They gave me a compound cream for nerve pain and with that and PT it started to feel better.  
Dr Blake's comment: Now, it is sounding better. The PT and topicals are probably working solely on the compensatory pain. But, the original problem goes undiagnosed. Have you found a shoe or boot/walker that allows you to walk comfortably. Sometimes, online purchase of a short leg walker from Ovation Medical and 1/4 inch adhesive felt from you can fashion a custom made boot and padding to off weight the area. 

But I still could not walk right.  I saw another Foot Doc from Hss for a second opinion and he said a nerve traction injury and it could take  2 years to calm down and to find good shoes.    He was against the cortisone shot as he said he saw idiosyncratic reactions that caused flare ups of nerve pain .  At this point I could walk around the house and short distances but was still not pushing off with the big toe or really stretching the arch at all when walking. 
Dr Blake's comment: It was a good decision to avoid the shot which can irritate an already irritable nerve!!! And, you were getting better. 

 The nerve pain seemed to be under control so I stopped using the cream.  2 days later the ball of the foot opened up and started to work.  My PT felt all my problems were with the FHL tendon as it was stretched and strained by the injury and this was where the tenderness and pain was.  The PT started me with very mild walk thru exercises to get my big toe to grab. 
Dr Blake's comment: I get very scared with this. The nerve is still irritable, and the system still too delicate. Weight bearing exercises are potentially too aggressive at this stage with so many wonderful less aggressive, non weight bearing exercises to chose from. 

 He did some massage to get the foot moving.  It helped somewhat but the more I could now make the foot move right( using the arch). The nerve pain came back. 
Dr Blake's comment: The art of medicine is in the timing of things. This was predictable. Your system still too irritable. Nerve pain, even when gone, needs a long time of respect before it allows a lot of stimulation. I love to keep patients on those creams for months after the nerve pain is gone. 

 It would burn at night and after a good day when I was able to walk barefoot around the house without a limp and felt the big toe start to grab that night it burned and hurt to just rest my heel on the bed.  At this point I still could not go down stairs although I could go up.  I could walk 2 aisles in the grocery store and then it would hurt in the arch.  Not able also is that once the nerve pain started I could not use ice it made it hurt more.
Dr Blake's comment: Angry nerves love pain free massage, heat over ice, gentle stretching. The nerve pain is secondary to your original injury, but now a major player. See if Low Dye taping is tolerated to support, but not press up. You course of events is very common, and some of it predictable, so cures can be found. Read all I have on the blog on nerve pain and tarsal tunnel, and CRPS. Many tips will be there.

 Also my first PT gave me exercises to do that had me lifting the forefoot off the ground while keeping the heal on the ground.  These made the foot hurt so much and my PT now said that was stressing the inflamed FHL.
Dr Blake's comment: It was just not the time to do weight bearing exercises. You were in the Immobilization Phase when some very simple exercises are needed, the diagnosis needs to be confirmed, anti-inflammatory measures rule and the creation of a pain free environment is paramount. 

  I decided to go back and see my foot and ankle dr prepared to get the cortisone shot to calm the inflammation.  He still said the next step would be to do the diagnostic lidocaine so he could be sure to know where to put cortisone. So I did it and it was a Hugh mistake.  The shot was placed in the tendon sheath by the knot of Henry.  The foot became numb from mid foot down and I had no pain for12 hours.  When it wore off my foot exploded in pain.  All the nerve pain was back and now it hurt to just gently run my finger along the FHL tendon and in that spot in the arch in the middle of the foot. 
Dr Blake's comment: I have only done this once to a patient, but it will live in my memory until I die. Injecting even local anesthetic into an unstable nerve is risky. I understand the principle of what he was trying to accomplish, but I am sorry that you had to experience it. Nerves like this can be unpredictable for several years. The symptoms can last for 4 days to 3 weeks. You must calm the nerve down with icing, or heat, or just rest. No compression at all. See a pain management specialist for oral medications (typically neurologists or physiatrists). Start using the nerve cream again if possible. Lidoderm patches are wonderful for this and you primary may be able to write for. 

 I talked to the Dr and the Dr who gave me the shot ( ultrasound guided at Hss). They had never seen a reaction like this and were confounded.
Dr Blake's comment: I am probably not as good a doctor as them, between me and my colleagues, we have seen this a lot. 

  I was left on my own.  The ortho said go to a neurologist.  It's been two weeks since the shot.  The foot is better but has been sent back beyond the beginning.  My PT did some massage and I had a good day and thought perhaps it was passing.  Then he massaged the FHL tendon deeply ( I don't think either one of us realized how re inflamed it was) and since then (last Wednesday) the foot is burning and I can' walk between rooms without burning pain in the arch of my foot.   And now the ball of the foot is re inflamed and swollen!  Back to the beginning!  On Friday
Dr Blake's comment: Please get this calmed down, and do not do anything until you email me. See if your area has a physical therapist that specializes in neuro-based PT, totally different then typical musculo-skeletal based PT. You should read the post on Checklist for treating CRPS, and begin understanding how to treat nerve pain. What ever your original injury, you now have a nerve injury that needs to be honored. 

 I went to the neurologist who was no help.  I did refuse Emg test since the foot is  so inflamed and had such a reaction to the lidocaine shot I did not trust that it would not further inflame the foot. 
Dr Blake's comment: Thank you for so much common sense!!!!! It is all in the timing. It is not the right time with the nerve so grumpy!!

 He sent me across the street to some bigwig podiatrist who heard my story hardly examined the foot and said RSD.  He sent me for an ultrasound and X-rays which I will get back at weeks end.  Both my ortho dr's PA and my PT do not agree with RSD .
Dr Blake's comment: All bad nerve pain is not RSD, although some of the same concepts of treating RSD or CRPS will/do apply to you. One of my posts goes over the Harden classification for CRPS (modern day RSD). Our job my friend is to not develop it with repeated flares over and over again. 

  I have no color or temperature changes and my pain is still pretty much contained to original area of injury.  My PT has treated a lot of RSD and said its simply not presenting that way.  He can massage it and it only hurts after.   He is at a loss.  After that shot just simple stretching of the FHL inflames it.  He will continue with ultrasound and TENS and he and the PA said just stay off of it for a few weeks ( something I' ve never done). So here I sit on the couch 21/2 months later unable to walk with a bunch of baffled pros.
Dr Blake's comment: Believe me, I give tons of second opinions, and you are catching this cycle so early. You have to stop thinking of time right now, and focus on healing, which may take a long time. But, it will be as logical and all your flareups have been once we realized you had a bad nerve reaction. It brought you from an orthopedic/podiatrist/physical therapist injury into the world of nerve pain. 

Dr. Blake I am not doing well with this.  I could face a definitive illness with a path and plan for recovery but this no knowing what it is or how to treat it and all the missteps by pros (HSS for goodness sake) has given me terrible anxiety.  I can't sleep or eat and feel out here on my own.
Dr Blake's comment: This is the realm of nerve pain. It causes suffering, where orthopedic injuries to the musculo-skeletal system cause inconveniences. I think you understand what I am saying. You need to create a pain free environment while you find docs/PTs that understand what I have just said, and can treat it. I will help as much as I can, but locally you will find your best options. 

  Even my GP of many years who I love says he just does not know what to do.   What are your thoughts?  What should be my next move?  My PT suggested going to a physiatrist he trusts that could coordinate things.  Should I go to yet another ortho?  What do you think happened with that shot?  Have you seen this before?
Dr Blake's comment: Yes, the physiatrist is a great choice. Right now stay away from the orthos or pods, unless you hear of one that has a knack for nerve pain. Also, find a neuro PT, even if the PT you are seeing does not like me for suggesting. Unless, I hear a better rationale for treating your nerve pain, I do not want any one but you massaging your foot. 

  I know the one ortho frowned upon the cortisone injection and said its always risky for a shot near a nerve.  At the time I thought he meant a cortisone shot but maybe he meant Any shot could irritated the nerve?  Do you know any great podiatrists in the NYC area.  Any help would be so appreciated. I am lost.
Dr Blake's comment: I only know 3 great sports podiatrists in New York State: Dr Karen Langone, Dr David Davidson, and Dr Robert Conenello, but maybe they could point you in the right direction. Believe me, there is nothing in what you said that does not make sense, that podiatrists have not seen, that treatments do not exist. Hang in there, and I hope this helps you some. Rich

Thank you, S

Patient's Response:

Dr. Blake,
Thank you so much.  I've been completely resting the foot and the pain goes down to almost 0 if I don't move it or walk on it.  Is that a good sign against RSD?  The PT did deep massage on the FHL tendon right under the big toe and gentle stretching ( pushing the foot back from the ball of the foot) now the ball of the foot is painful and swollen again-could that have been the reason?
Also, the nerve cream stings when I first put it on which it did not do originally- is that ok?  And lastly- Dr Conenello- is he great?  He is right by me -  would he be a great choice to guide me thru the rest of this rather than the physiatrist? 


Dr Blake's response:

S, Glad Rob is close, he is kind and smart. You need someone to manage your foot while a physiatrist works on the pain. No shots for now, in your foot at least. Rob may know where to send you, or if he is qualified to help. A good new start!!! You need a team however. With nerve pain, there are times to Honor the Pain (now), and times to Push Through the Pain (someday). You definitely need some weight bearing, some massage, some ankle rotations, some achilles stretching, etc, but start slow. Take it 2 weeks at a time with the next 2 weeks to get new direction, not irritate your foot at all, experiment with ice and heat, continue with nerve cream but gently, get into someone who can put you on Neurontin or Lyrica, and keep me in the loop. Rich

1 comment:

  1. I really hope you are able to get this turned around soon. I feel for you. Myself and others have not had good experiences at HSS so I caution anyone to not fall in love with the place just based on their name of implied excellence. Don't be afraid to move on.


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.