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Sunday, January 21, 2018

Mechanical and Neuropathic Pain: Seeking a New Direction of Help

HI Dr. Blake:

My name is Francine (name changed due to witness protection) and I'm 45 years old.

 I came across to your youtube video of the talk you gave at the SF Main library, after going to see a podiatrist a few weeks ago. Coincidentally, the lady who arranges the library lectures is an acquaintance of mine who lives in the same complex as my mom, who later, after I mentioned of my chronic severe back and feet problems, recommended your office.

I was very excited to have seen your youtube video. I feel the compassion you have for your patients and ppl living with unnecessary pain. I thank you and whoever videotaped that video and to put it out there so many ppl can be helped.

Please excuse this little history:

I have had chronic back and feet problems probably for at least 20 years. Started with rounded shoulders (possibly bad posture and the heavy backpacks back in the day). I have seen probably a few massage therapists, PT, chiropractors (upon recommendation) to little relief. 

About 6-7 years ago I knew my feet hurt (the outer edge as I walk excessively on the outer heel and edge of my feet, as seen by the many pairs of excessive worn out heels from shoes. at the time (6-7 years ago I'm estimating the time frame) I saw a podiatrist at Cal Pacific (had to yelp for podiatrists in order to jolt my memory) and at the time he had made a custom-made orthotics for me. I was very persistent in using it for about a month but it was very uncomfortable so I stopped. I never went to follow up with him. I recall he boasted about working with celebrities and I vaguely recall he mentioned I have the typical Asian "flat feet". 
Dr. Blake's comment: You describe excessive supination or being on the outside of your feet. Do you think you know if these orthotic devices helped that? Do you remember what bothered you about them? If you still have them, putting back in your shoes for several days may help you remember the pros and cons. If you were to get new orthotic devices, you do not want to repeat the same, you want to improve on it. 

I started hiking/walking/swimming about 3-4 years ago (but was pretty much led a sedentary lifestyle growing up) as I gained 25 lbs over the past 6-8 years ago, suffering tremendously from some women's health issues that plagued me most of my adult life. After 2 major surgeries to deal with the issues (almost 8 & 3 years ago), I began to deal with the chronic back issues. I would get severe migraines due to the hard rock stiffness and tightness of my delts, rhomboids, shoulder/neck areas and since then began going to a chiro, PTs that were referred to me, of very little relief temporarily and nil permanently. and then finding my own massage therapist (who has tremendously helped me). A year ago I went to a podiatrist at Mills Hospital as an episode hiking in the park (moderate, not even strenuous by standards) left my foot debilitated. The outer edge of feet was in sooo much pain/ discomfort I had to YANK OFF MY BOOTS during our lunch break for the foot to breathe for 15-20m. After lunch was over, we had to return to the cars. Thankfully this was all DOWNHILL. I limped the rest of the 2 miles to the car, using my better foot (left foot was support) and right foot using just the bottom 1/2 of the foot. So, this podiatrist at mills spent about 5 minutes with me. I bought some shoes for him to examine. And he said he would send me to PT and sold me an OTC insert. I asked him before leaving, "Well aren't you going to do a gait analysis" and he said no, that the PT will do so. Went to Mills for probably 7 of the 10 sessions. The PT could not figure out what 's up with my foot /feet. He had me do some exercises. He had me go on a treadmill. He worked on my ankle with cupping. He had to give my ankle "stimuli"...when he instructed me to raise my ankle I couldn't do it in isolation. My whole body moves. He had to lift it up a few times, then my ankle was able to imitate it. In a different session, the "cupping" for a few minutes was the stimulus that allowed the ankle/foot to fire up. This PT felt disappointed he could not help me and didn't want to waste any more of my money with the remaining sessions, which he felt would not achieve much. Sent me back to the podiatrist and at the appt w/ the podiatrist, he shrugged and said: "find an osteopath or physiatrist". I asked if he could recommend one and he said "google it" after all these years, I haven't had luck with dealing with I shrugged and continued my life w/ my 2-4 x monthly massage therapist while continuing to put this feet issue on hold. 
Dr. Blake's comment: I am so sorry for such poor medicine. The therapist just needed direction, but no excuse from my profession. We are supposed to give the direction. The crucial point you made is not being able to do a heel raise. If you can not do that, you can not walk well. Having a physiatrist or neurologist do a nerve conduction study will tell you if it is neurological or if it can come back. Also, what have you found in shoe gear to help yourself? Any correlation to less pain with a slight heel versus flat shoes? 

Fast forward 1 year and the feet is just KILLING ME. I decided to try ONE MORE TIME. Bear in mind I have little energy and my chronic feet and back problems are killing me physically and more so, emotionally. Besides the massage therapy and Chinese chiro work I do, I am pretty busy running around to yoga classes, heat therapy (sauna & spa for my back as suggested by the massage therapist) so it's not like I'm sitting around whining and feeling sorry for me. I have gone to yoga for 2-3 years, then tried machine pilates after pilates was too unrealistic w/ the back and no core, classes @ the gym (which killed my feet---ANY type of movvement, whether dance, exercise based aerobics, even low impact step class was EXCRUCIATINGLY painful on my feet, whether I was barefoot or with good shoes running/walkign shoes, shoes with the OTC inserts (happy feet), inserts I bought in asia more to the "asian" foot, the original custom made insole from 6-7 years (?) ago. The massage therapist asked me to STOP ALL exercises and walk on sand. I cannot bear to think that for the rest of my life I will have a life sentence for physical activities. I am now looking into belly dance and hula dance (for the hip movements for the lower back).
Dr. Blake's comment: Even though this is a terrible situation, I just love your spirit!! We need you to focus on what has helped you somewhat. We need to put this together to help you. So, if you write back, list the 5 things besides massage therapy that has helped. There must be parts of Pilates you can do, parts of yoga, etc. There seems to be a mechanical source of some of your pain and can be addressed hopefully with a more thoughtful approach to orthotic devices, but what are we doing for the nerve pain. This takes an approach to the Neuropathic pain, not mechanical pain or inflammatory pain. What have you tried? 

So recently, I saw a podiatrist who insisted on XRAYS, full spine & right foot. 4 degenerative discs in the lower back (possibly from being rear ended 3 years ago . LAdy hit me so hard my car hit the person in front). From what the yoga instructors tell me, my pelvis is shifted. Didn't pursue the driver as I was naive and didn't see any mds and didn't realize it could have compounded cause more back issues since I already had pre-existing back issues and I was plain naive. When I realized I should have sought treatment right after the incident the time limit surpassed.

Anyway, she suggested doing two stretches and the diagnosis said :
foot contusion, peroneal tendonitis, and exterior tibial tendonitis.

My question to her at the 2nd appt to review xrays was: 

how do we know if the original custom-made orthotic made 7+ years (?) ago is correcting/fixing the problem she's diagnosing? my recollection isn't' 100% but the podiatrist who made it just mentioned I had flat feet, but current podiatrist and shoe sales guy said I don't. So how do I know by wearing the custom-made insoles will help me? Further, I wore them in an exercise class and it hurt like hell. 
Dr. Blake's comment: First of all, the reason I asked the above question on whether they made you feel more stable, is that is what custom orthotic devices are about. They increase stability by decreasing pronation, decreasing supination, giving you a broader base of support, etc. Just because you got orthotics does not mean that they were designed for the right function. It takes work to figure that out, and they have to be comfortable also. Typically I can always make old orthotics comfortable by some adjustment, but getting them functioning well in some ways depends on how they were initially made (what were they trying to do). 

I was able to raise many examples and give a lot of good history for this podiatrist in my 1st visit, b/c having taken all the yoga, pilates, and other exercises I've tried the past 3-4 years gave me very concrete examples of what my body was/wasn't doing in classes.

Please advise. Do you think you could help? Do you think getting a new set of orthotics (now that I'm 25-30 lbs heavier) would help? I wished I followed up after getting the first orthotics, but I didn't know what I do today.

Living in excruciating pain. Would be very grateful to live and manage my pain.
Dr. Blake's comment: Where we start in my mind is easy. You are very clear you have mechanical issues, and you have neuropathic pain. I believe there is a better orthotic device for stability, I believe every exercise you do is helping with the overall body stabilization from muscle strength. I believe that their is a whole other area dealing with neuropathic pain that you have not tapped into. Neuropathic pain is excruciating. Anti-inflammatory pain produces swelling, redness, black and blue, have not heard those words from anyone in your description. To heal, or at least not make yourself worse, you have to live in the 0-2 pain level environment. Could you do that? Can you find out who is the best in orthotics in your area and go to them? Can you see a pain specialist, not for opiods, but to work on neuropathic pain? Can you go back to the therapist and say I would like your advice on how to modifiy my workouts to live in that 0-2 level? I hope it helps some. Rich

1 comment:

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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.