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Thursday, July 17, 2014

Severe Foot Pain from Trauma: Email Advice with Patient Response

Dr. Blake,

Thank you so much for your blog.  It is very informative and helpful.  It is easy to see that  not only do you love what you do, but how much you truly care about people too.

I have a situation in which the aftermath of injury is more complex than the initiating injury.  My toddler pulled an object off the dining table and it did a nose-dive into the top left of my foot, below and between the fourth and fifth toes.  I immediately went to my bed and hollered for ten minutes straight.  I never knew such pain.  This was followed by an attempt to walk, which I soon gave up and dropped to hands and knees in order to get around.  Unfortunately, my foot had already borne the weight of heavy limping in places it’s not supposed to.

The beginning was really tough-the first two weeks of healing were like having the flu, being crashed in bed most of the time and sleeping as much as possible.  Physical response included extreme fatigue, severe swelling, pain, severe discoloration (deep purple/bright red/pale), throbbing, severe skin temperature fluctuations, inability to walk or tolerate pressure (not even a bed sheet!) A few weeks later I noticed a soft, squishy lump inside the bottom of my heel that made me feel weird, but when I tried to check it again, it was gone.
Dr Blake's comment: This may be what is called neural over-reaction or Complex Regional Pain Syndrome. 

Due to certain circumstances, the medical care I received at the start was not very adequate.  No one knew what happened to my foot and I heard different things from different doctors.  Even the same doctor told me at one visit, while looking at the x-ray, that my foot was broken right “there” (AAYYY!) and at the very next visit said no, it’s not broken and there’s no evidence that it ever was (what evidence was he looking at??)  I was completely off my foot for about 10 ½ weeks due to pain and swelling, but did manage to pull my over-sized foot out of the aircast, stuff it into a tennis shoe and hobble without crutches before he released me.  It was around a similar time that I could (finally!) place my bare foot (with no weight) flat on the ground.  This was around three months post-injury.

Six months later I still had a constant limp, swelling, discoloration, pain, wrong temperature (usu. too cold), lack of function, stiffness, tingling nerve, and I went back to the doctor (different one this time).  I’ve been working with her now for about four months.  I’ve seen some improvement first in function and circulation, second swelling, and improvement in pain is much slower going.  My primary pain points are the heel, arch, across ball of foot, sesamoids and big toe.  Swelling always causes pain to increase.

Over the past thirteen months my diagnoses have been described as:  possible bruised bone, no one ever agreed on whether or not my foot was broken, sesamoiditis, callus, plantar fasciitis, varicose veins, medial hallux neuralgia, IT band syndrome (both legs, from limping too long), and lumbar strain (for which I had to go to another dr.)  Treatments have included a short aircast x 5 wks, Powerstep orthotic (all the time), steroid pack, several applications of Unna boot, a below-knee compression sock, and PT including iontophoresis and Graston technique (left foot and both legs), and of course icing (with a cold pack). Back treatment also included some anti-inflammatory meds.  A flare-up of anything (left foot-legs-lower back) has the potential to aggravate the whole system.

So here are some of my thoughts-
Will I ever be able to run, jump, tiptoe and stand in the shower?  Return to normal function?
Will I ever be mostly pain free/able to bear full weight (esp. sesamoids, big toe, and across ball of foot)?
Why do I still have pain and swelling?  Occasional swelling inside the compression sock?
Can I get orthotics for my ice skates if I ever make it back onto the ice (non-competitive)?
How long do I stick with PT?  Current doctor?  Get a second opinion?  Which medical discipline?
What can I expect long-term?  Will my foot ever feel ‘normal’ again?  How do I exercise?
How do I keep the system in balance and not aggravate opposing-injury cycle?

If I lived anywhere nearby, I would definitely set an appt. to see you.  I am truly blessed to have found your blog and thank you for any input you are able to give me.

Marie (pseudo name)

attached are a couple of pictures

The swelling and redness are common parts of some presentations of CRPS. It is called vasomotor insufficiency. 

Dr Blake's comment:

     Marie, I am so sorry for your problems. It sounds like you have a version of Complex Regional Pain Syndrome. There are so many treatments for this, and you need to be in the hands of a podiatrist and pain management specialist in your area who are knowledgable about this disease. If that diagnosis is confirmed, my blog is full of many ideas on treatment. I hope this is helpful to you. Rich

Marie responded several weeks later: 

Dr. Blake,
Thank you so much for your reply.  I saw a local pain management doc and a diagnosis of CRPS / RSD has been confirmed.  I am very grateful because without your input, there is no telling how long it might have taken me to get an accurate diagnosis.  It does not seem to be very well known among doctors.  Now I have the opportunity to move forward with treatment / management.  My question is:  what role does a podiatrist play in treating CRPS?  My current podiatrist does not appear to be familiar with it at all.
I'm including a few photos from three weeks and nine months (last photo) post-injury, in hopes of educating people on what CRPS can look like.  Perhaps someone else will have the opportunity for a much-earlier diagnosis.
Thanks again for your help.
Forever grateful,

Dr Blake's Response:

     I am so happy to have helped since making the diagnosis is crucial to getting the right treatment. You will see from my blog that treatment should be a Team of people, with a podiatrist helping. A sympathetic block is typically important now, but oral medications can crucial. If you see my checklist of treatments for CRPS, you will see how creating a nerve non stimulating environment is crucial. The podiatrist, if knowledgable on this condition, will be invaluable along the way. Also, definitely check if you have a Calmare Pain Therapy center near you. Let me know how I can help further. Rich

And here is info from an article I am writing. 

4. Lessons learned from the treatment of Complex Regional Pain Syndrome

I am treating many patients right now with a diagnosis of Complex Regional Pain Syndrome. It is a very difficult topic, and one I have known for a while I needed to present somewhat on my foot blog. It is a gross understatement to say I am treating them, since they can only be treated by a team of people since it is too complex. The most important person on that team is the patient, and they really call the shots. If you are given that diagnosis, also known as Reflex Sympathetic Dystrophy or RSD, and others, you are scared. The doctors and therapists who treat you are scared for you. The quicker the response that better, but even those whose diagnosis is made at a snail's pace can get better. I love to see these patients every 2 weeks since there is so much to do and get organized. The visits should be a constant exploration and expansion of these Mainstays of Treatment: Identifying the source of pain, completely eliminating the pain cycle, nutrition, rehabilitation of limb function, being as productive as possible, and handling comorbidities of anxiety and depression. I hope this summary does help those suffering make sure nothing is being forgotten, and every visit to the managing doc is as productive as possible.

The Mainstays of Treatment are:

·       Identifying Source of Pain
1.      MRI/CT Scans
2.      Bone Scan
3.      Diagnostic Injections (local or back)
4.      Nerve Conduction Studies
5.      Lab Tests
§         Sed Rate
§         CBC
§         Free T4 and TSH
§         Vit B12 Levels
§         HgbA1c
§         Morning Fasting Blood Sugars

·       Completely eliminating/breaking the Pain Cycle
1.     Mechanical Means
§         Roll A Bout
§         AFO
§         Crutches
§         Tibia Wt Bearing Braces
§         Activity Modification
§         Custom Made Orthotics to stabilize an injured area

2.     Oral Medications
§         Anti-Seizure (ie Lyrica)
§         Anti-Depressant (ie Nortriptyline)
§         Others through Pain Management Specialists

3.      Topical Medications/Applications(should be gels for ease of application)
§         Warm Compresses
§         Non Painful Massage
§         Parafin Wax
§         Chinese Herbs
§         Lidoderm Patches
§         Neuro-Eze
§         Multiple Compounding Medications which include (usually not all of these):
ü      Ketamine 10%
ü      Clonidine 0.2%
ü      Gabapentin 6%
ü      Baclofen 2%
ü      Nifedipine 2%
ü      Lidocaine 2%

4.     Alternative
§         Biofeedback (Thermal to increase circulation)
§         Hypnosis
§         Meditation
§         Accupuncture (can be to opposite limb or ear)

·       Nutritional (next 3-12 months)
1.      Lipoic Acid 300mg 2x/day
2.      Acety-L-Carnitine 2000 mg/day
3.      Inositol 500-1000mg/day
4.      Vit B6 50mg/day
5.      Vit B12 1000mg/day
6.      Vit E (up to 1,600units/day)
7.      Thyroid Natural Supplements

·       Rehabilitation of Limb Function
1.      Lower Extremities (keep strong as long as painfree)
2.      Core (support feet and legs from above with less pressure on feet overall)
3.      Cardio (improve overall circulation and health)
4.      Whole Body (must address physical, emotional, spiritual sides together)

·       Being as Productive as Possible (while nerves are healing) Can Help Nerves Heal Faster
1.      Part Time Work
2.      Volunteer
3.      Projects

·       Dealing with CoMorbities of Anxiety and Depression

Possible Sources of Information/Support/Inspiration
ü      American Chronic Pain Association
ü      American Academy of Pain Management
ü      Reflex Sympathetic Dystrophy Syndrome Association
ü      How To Cope With Pain blog


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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.