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Thursday, November 5, 2015

Chronic Forefoot Nerve Pain: Email Advice

After baffling yet another Doc with my condition, I returned to the internet in search of a sport medicine podiatrist and came across your blog.
If you could offer any advice I would certainly be grateful. My situation is as follows (if you are able to help I can provide more detail J):

·        57 year old male – was active and in good health.
·        While recovering from bilateral quad tendon issues I injured both forefeet in 2012 while hiking for 2 days in a caved area with stairs and slopes. To protect the quads I went up many, many stairs using my feet and calves (think of it as doing 4,000 calf raises).
·        Result was bilateral stinging pain on the balls of the feet, the metatarsal marble sensation and sharper pain with dorsiflexion of 2 and to a lesser extent 3 and 4. No issue with great toes. And no foot issues whatsoever prior to hiking.
·        Upper body issues have been ruled out – very confident on that.
·        Failed treatments over 3 years have included: cortisone shots, orthotics, regrettably a right foot bunionectomy and shortening osteotomy on 2 along with pinning 3. Did PT and then was sent to a pain clinic. Next Doc focused on the left foot and performed a 2/3 neurectomy. No relief and told cannot treat if cannot diagnose.  Indicated I had no serious issues such as cancer, etc.
·        Current status is broad ball of foot stinging sensation that escalates with use (now constant), marble sensation on metatarsal heads (left 2 and 4; right 4), and toss in some stiffness and numbness from the surgeries! No swelling. No toe drifting on the left foot; slight pulling down of 3 on the right foot. Aggressive stretching = stinging, sometimes on a delayed basis – i.e. the next day.
·        I have had 3 MRI’s (generally unremarkable according to Docs, but may provide some insight) and 1 diagnostic ultrasound (identified micro tears on the plantar plate).
·        I have been wrestling this for 3 years and feel my condition is deteriorating while my activity level is very low.
·        I buy into your concept of getting to a 0-2 pain level and then progress from there – but could use assistance  developing a course of action.

If you are willing to help, I can get my hands on the MRIs and ultrasound reports or answer any questions you may have.

Thank you for considering my situation.

Dr Blake's response:
     Thank you so very much for your email. It sounds nerve related more than plantar plate, at least this would be the area to explore. Nerve Pain is helped by some combination of the following (many of these topics are in the blog already):
  • Neural Flossing three times daily (find out if sitting or laying techniques more productive)
  • Nerve Pain supplements like B12, Vit C, (gradually you add one per month to check effectiveness,  so you would wait on this right now) etc 
  • Some topical nerve cream applied 4 times daily (NeuroEze or Rx)
  • Heat over ice
  • No sciatic nerve/calf stretching (find out everything postural wise that is tasking your sciatic nerve from beds, sitting chairs, standing habits, workout techniques). 
  • Oral meds (start with evening doses only of Lyrica, Neurotin, or Cymbalta). 
  • Epidural injections into L5 nerve root
  • Soft based orthotic devices like Hannafords
  • See if there is a Calmare Pain Therapy center near you 
  • Sometimes TENS and Capsacin is helpful (but you have to go through 14-20 days of more pain first)
Hope this points you in the right direction. Rich


  1. Thank you for the feedback!

    Can you elaborate a little on the sciatic nerve / calf stretching? Other Docs have told me that tight calves / hamstrings were part of the issue and that I should stretch these.

    Also, I recently tried icing in a bucket of water with ice cubes. After a minute or so it felt like I had been abducted by aliens specializing in foot torture! The sensation was similar to when you "freeze" your feet by staying in cold weather too long and then they "thaw" after coming inside producing intense pain. I've iced in the past for sprained ankles but never had such an intense reaction. Does this heightened sensitivity to cold support the nerve related diagnosis?

    I ordered the neuro-eze and will proceed with acquiring an RX for the oral meds you suggested.

    Up until now I have only consulted with foot Docs, except for a couple of visits to a pain clinic as mentioned previously. To pursue your suggested course of treatment for nerve pain, would you recommend working with a foot doctor, pain specialist, sports medicine MD or family doctor?

    Thanks again.

    1. Ed, typically it has to be a combination of foot doc and pain doc. Yes, nerves hate ice and love heat. Nerves love gentle motion (like neural flossing) but not prolonged stretching. Massage is +/- depending on how deep you go and how vigorous. Good luck. Rich


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.