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Wednesday, June 4, 2014

Nerve Pain: What to do next?

Hey Dr. Blake, 

I keep up with your blog and I'm so sorry for your recent losses. Hope you are ok. I'm having trouble with my foot again and wanted to ask your advice, if you are up to it. If not, I understand. In case you ARE up to it, here's what's going on...

I can't get the pinched nerve (the Big X in the pics below) to calm down. I've had it padded a million ways (not sure I'm padding it properly either) and when I take the pads off and take a full step, it's zinging me just as strong as when it first started. I have been able to walk on the foot with the pads but I'm starting to get blisters and callouses on the side of my big toe from walking all weird from the padding and trying to avoid zinging myself by stepping on the pinched nerve. I did not and do not ice like you suggested (3x a day). I can but I don't because...I don't know why. Lazy, too busy, etc. So if that's what I need to do before anything else, I will make it happen. 

Terry (name changed)

Dr Blake's response:

Hey Terry (you know who you are!! LOL),

     Thank you for the concern. I have been in a fog, but trying to help you and others does help get me centered. Thank you very much.

     First of all nerve pain/abnormal nerve sensations can forget to shut off even when you protect them for extended periods of time like you have. The old saying is that "if you look at a nerve funny it will hurt for 9 months" is fairly true. When treating nerves should be addressing 4 areas---mechanics (which you seem to have mastered), anti-inflammatory (and ice 3 times daily is the easiest), nerve hypersensitivity (oral meds, topical meds, neural flossing, injections), and diagnostics (MRI with contrast, Nerve Conduction tests, etc). 
Please email me back on what areas you have done and could do in each of these 4 areas. Rich

And the response:

Thanks for the response! Wow, I had no idea nerves could take so long to calm down. 

Mechanics - I think I am doing this right if that means not feeling the pinched nerve "activate" while I have the padding on. Most of the time I don't. This past week I feel it even with the padding on. For the last 3 weeks, I have been extra active and on my feet for much longer each day than normal. 

Anti-inflammatory - I am not doing any at all. So I can begin icing 3x per day. Any other ways?? 

Nerve hypersensitivity - not doing anything at all. What should I do?? 

Diagnostics -I never had the swelling or the level of pain for this nerve that I did for the original injury so I haven't done any new diagnostics. I just have the old MRI and X-rays that were done before this new pain started. I am not able to get a new MRI right now due to financial constraints and a super high deductible. 

Dr Blake's comments:

     Mechanics: So right now stay where you are at and avoid barefoot if that is irritating you. Some of my patients during flares will go into already tested removable boots or hike and bike shoes, or something that always works, and stay in it for a 2 week period.

     Anti-inflammatory: Definitely we need to see how 10 minute ice pack on the bottom of your foot works first 3 times a day. You can add 2 advil or 1 aleve occasionally. You can also massage into the area arnica or traumeel. 

     Nerve Hypersensitivity: Go online and purchase Neuro-Eze and massage into the area 3-4 times a day for one month. Also, look at the blog for the video on neural flossing  (aka neural gliding). Do that 3 times a day. 

     Diagnostics:Remind me what the old MRI showed since this is the best test. However, getting a neurological examination to look at the whole sciatic nerve (even the spine up to the neck) to have see if you are getting neural tension anywhere. Simply having a PT evaluate how you sit and lift, etc, to give you tips on posture and how to minimize the day to day stresses on the sciatic nerve can be helpful. 

     Please give me feedback. Thanks Rich

The patient's response:

Ok, thanks!! I will begin all of these suggestions ASAP. (I am icing as I type this!!) 

Here are the MRI results. The MRI was about 2 months before I started feeling this nerve pitch. Nothing particular happened that I am aware of that caused it. I was doing well and recovering from the original injury. But as you can see from the pics, this nerve pinching that's bothering me now seems to be right in a line up my foot from the original injury. 

MRI FINDINGS: Dorsally located subcutaneous nonspecific edema of the forefoot is noted. No stress fracture is currently noted. There are bursal effusions especially between the 2nd and 3rd, 3rd and 4th and to a lesser extent 4th and 5th metatarsal phalangeal joint. Subtle flexor tendon is noted third ray. These findings are compatible with bursitis, synovitis, and mild tenosynovitis without associated stress fracture. Phalangeal sesamoid ligaments appear unremarkable. 

IMPRESSION: 1. MULTIFOCAL BURSITIS, nonspecific soft tissue edema with no stress fracture noted. 
2. The Lis Franc ligament is intact. 

Dr Blake's response:

    All of the original MRI findings indicate inflammation, but does not rule out inflamed nerves (they can be hard to see, especially with the bursitis inflammation). If we get another MRI down the line, then the expensive one, the one with contrasts, should be done since it can give more information. Ask your doc about a 8 day Prednisone Burst to jump start the anti-inflammatory attack. Rich

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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.