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Friday, September 21, 2018

Nerve Pain: Possibly Treating the Wrong Area

Hi Dr. Blake,

I too experienced severe pain/side effects after my first alcohol injection. It has now been 7 weeks after my last injection (7 in total) and I'm STILL in pain - as a result, from the shots. I didn't have this type of pain, or in this location prior. Here is a summary of my story leading up until this point:
  • Stubbed/fractured/broke/ right pinky toe Nov 2016 (was pain-free prior)
  • Went to podiatrist May 2017 who suggested tape and increase vitamin D dosage due to deficiency
  • Toe seemed to make progress into Nov 2017 but then healing plateaued and eventually worsened
  • The orthopedic surgeon said they couldn't help since X-rays/MRI showed no damage(Normal results - Morton's Neuroma was NOT shown)
  • Podiatrist suggested 9 laser treatments on the bottom/side of the pinky toe (not the neuroma since this wasn't diagnosed at the time). All 9 were performed by 2 physical therapists and no long-term relief was evident.
  • Podiatrist performed an ultrasound and diagnosed me with Morton's Neuroma. Found interesting since the pain I was experience was not where the 2 neuromas were located. I did not have the typical symptoms listed for MN at that time and the diagnosis didn't match MRI...but he convinced me this was causing my issue.
    • Podiatrist suggested 7 ultrasound guided alcohol injections on my right foot. (30% in both neuromas per session).
    • The 1st shot had horrible side effects: increased pain, numbness, tingling. Caused common symptoms of Morton's Neuroma, which I hadn't experienced prior.
    • 2nd shot provided relief to some of those symptoms.
    • Started noticed an improvement in injection 4/5. Feeling optimistic!
    • The pain started to come back slightly after injection 6
    • Injection 7 was now 7 weeks ago. The pain came back both in my pinky and neuroma. There was visible external bruising after this injection which has subsided but I'm still in pain.
  • Dr. Blake's comment: The initial reaction is unfortunate, but probably one in 5-6 patients, and always resolves. The series should stop at five to rest the tissue. Not sure why you kept going. Actually, from your explanation, many neuromas never hurt ever, so why wake up a sleeping dog? 
  • I'm now in more pain today than I was prior to treatment! (although less so specifically in my pinky toe...and the pain comes and goes more frequently than prior)
    • Prior to injections, I did not have any typical Morton's Neuroma symptoms (no burning, tingling, etc.) But now I do, in addition to my chronic toe pain.
    • After injection 7, my right foot now physically looks/feels swollen underneath my toes. I'm not sure if this is the neuroma, pools of alcohol from the shot, or hematoma. 
    • Dr. Blake's comment: I hope you are in a removable boot to rest the tissue for the next month. Sometimes 5 minutes of ice frequently is best, and sometimes several warm water soaks of 30 minutes each twice daily is very smoothly. The MRI taken should tell you if the swelling is anything to worry about, but swelling from pain is normal with this type of problem. It is telling you to quit irritating me!! 
      • My podiatrist didn't have an answer for me and said this has never happened before. He Rx Lyrica to reduce the pain but I didn't feel good on it and the pain relief was minimal
    • I got a new MRI. And my podiatrist says it looks like one neuroma shrink over 50% and the other is marginal compared to the other...But again, I'm not in more pain since starting the injections.
    • I've had pain every day of my life for almost 2 years. I thought these alcohol injections were going to be the answer but now things are worse.
    • Dr. Blake's comment: Definitely get the MRI report to read. You can send me the report because you need to know if there is anything else to be concerned about. Probably not. This pain should cool down over the next month if you do not keep irritating. Do you know the alcohol percentage used? I just do not think from what you say you are treating the right thing. I am not saying to switch either yet. Please wait the next month, go in a boot. Try to topically cool it down with ice or soaks. 
I've attached an image of my current pain/discomfort. The skin is still sensitive in that area when touched.

My podiatrist has presented some alternative "plan B" options (laser treatments on the neuroma or stem cell, amnion-chorion membrane injection) but these are not covered by insurance, costly, and I'm afraid it would only provide short-term relief if any. Based on my MN support groups - most people said this was a waste.

Please share any thoughts and suggestions you have regarding my case.

Thank you for your time.

Dr. Blake's comment: I need to know if you are off-weighting the area with Hapad or Dr. Jills products. My blog has many examples. You should be massaging three times a day Neuro-Eze cream (online product) and doing neural flossing until the new symptoms better. Get in the boot and relax this. Rich

The patient responded:

Hi Dr. Blake,

Thank you for your quick response! 

Some follow up information/questions:
  • I was told they were 30% alcohol sclerosing injections with the intent to shrink the neuromas. 
    • I was given 2 injections in my right foot for each of the 7 sessions. I have attached images of the injection areas. As you will see, this was not near my original source of pain (pinky toe).

  • Dr. Blake's comment: This is a lot of irritation. The highest percentage that I have gone is 20%, which is what I have found podiatrists in the UK are using. Plus, giving it in 2 places at once is more chance of irritation. This may be fine, but no more shots, especially since it was done for MRI findings, and possibly not for the reason you needed to be treated. 
  • I kept going with the injections because my doctor suggested all 7 for my case. I felt maybe 80% relief after the 5th injection so it made sense to continue on my doc's advice thinking it would get me to 100% relief instead of reversing and causing more/new pain.
  • Dr. Blake's comment: With any injection series, and probably for most treatment protocols, you try to get the patient to 80% better, with the remaining 20% allowed to father time. 
  • "Many neuromas never hurt ever, so why wake up a sleeping dog?" - Only because my doctor believed the MN diagnosis was the cause of my chronic pinky pain.
  • Dr. Blake's comment: If you give a 5-hour lasting local anesthetic into the neuromas first, and for that 5 hours the pain in the pinky toe disappeared, then addressing the neuromas in some way would make sense. 
    • If my chronic wasn't wasn't from MN - what else could have been causing it? Perhaps RSD/CRPS?
    • Dr. Blake's comment: When you stub your toe, and then have chronic pain and negative xrays and MRIs, you may have some version of CRPS although the injury could just be missed in the films due to its superficial location. Besides the laser treatments by the PTs, you really have not had a thoughtful approach to where you hurt. Once the pain goes away from all these shots, you may have to investigate various options like joint mobilization, ultrasound as a treatment, acupuncture, off weight-bearing padding. Just sending me a photo of what types of padding minimize your symptoms would be a good start. 
    • Is it possible for these injections to cause more long-term harm than good? (My fear is that my chronic pinky toe pain has turned into chronic foot pain)
    • Dr. Blake's comment: In December, as long as you have had no more shots, a new MRI will be done if some of the injection pain lingers. 
  • No one has recommended a removable boot until this post. Happy to give that a try. Is there a specific brand/model you would recommend? Dr. Blake's comment: yes, anklizer by Bird and Cronin is a good one or the short style (just going above your ankle) by Aircast.
    • Is this something my doc could Rx and be covered by insurance, or am I better off just buying on my own online? Dr. Blake's comment: Your doctor's office will know. They are around $60-70 self-pay.
    • In the meantime, I've spent most of my time at home in slippers with custom Rx orthotics. When I'm out, I'm in wide sneakers with the Rx orthotics as well
  • I've tried both hot Epsom salt baths and ice without luck... In the past the bath would make the sensation further "radiate" and the medical ice pack would cause a "burning" sensation. But if you suggest one over the other I can try to do that more consistently.
  • Dr. Blake's comment: We have to assume you may have an internal burn. The general rule is no ice on a burn, so some warm compresses are probably best. Try a warm slightly damp facecloth on the area when you sit and wrap saran wrap around for 30 minutes at a time. The saran wrap allows the heat and circulation to get deeper. Whatever you do, you should at least immediately feel better. 
  • I have a copy of the full digital MRI on CD. Happy to send this to you to review if you suggest a certain file type. (can your computer read a .iso CD image file or anything else you recommend? I can also try taking some screenshots from it)
  • Dr. Blake's comment: I am not sure which ones. Can you have a disc burned and sent to me at Dr. Rich Blake, 900 Hyde Street, San Francisco, Ca, 94109? Any screenshots as photo images are fine also. 
  • I do not have a copy of the report. I will request this next week. When I asked my doctor about the results, this is what he told me:
    • "The MRI shows only mild residual neuroma remnants following the injections. No other major boney or soft tissue pathology. Dr. Blake's comment: Hooray!!!
    • [The size of the neuroma is not indicated on the MRI Report] When I looked at it myself, it looks to be 6 MM or less which is small and over 50% of the one neuroma and marginal on the other as compared to the original ultrasound I did on April 2nd which showed:
      • Findings body of the report. We noted a 14.0 mm ovoid hypoechoic ill-defined nodular density seen on sagittal view in the right 2nd interspace. And also a 6.9 mm ovoid hypoechoic ill-defined nodular density is seen on sagittal view in the right 3rd interspace. No evidence of bursitis, capsulitis, or plantar plate tear in the right 1st, 2nd, 3rd, 4th, or 5th MTPJ's."
  • I was Rx a couple of different topical anti-inflammatory cream. I was told to use these simultaneously but they failed to provide relief. Dr. Blake's comment: Makes sense, your pain is nerve pain, get one for nerve pain and also try Neuro-Eze. 
    • I have not tried or heard of "Hapad or Dr. Jills products" . Which would you recommend for my case? Dr. Blake's comment: Both companies sell online. You could ask the podiatrist which one offloads the area best. I would try a small longitudinal medial arch Hapad support as a metatarsal support. But we have these right in the office. 
    • I haven't heard of neural flossing. I found an older blog of yours with a video. Is this what you recommend I do in my situation, or is there another type of neural flossing suggested for MN? Yes!!
  • What are your thoughts on Dr. Blake's comment: I think acupuncture right now makes sense as long they do not stick the sore area. You have a nerve problem, and acupuncture addresses that. 
    • MLS Laser treatment?
    • Amnion chorion membrane injection?
    • Acupuncture?
    • Nerve decompression surgery?
I rather not seek any other type of treatment if you think I simply need more time to heal...but my doc said my symptoms should have resolved 4-6 after the last injection and it's now been 7. Maybe the boot would have helped but I've been fairly inactive during this time.
Dr. Blake's comment: You can not use time, because everyone is different. That being said, get in a boot, start treating the nerve pain without increasing pain, be nice to yourself, see how you are in 3 weeks. I want a report. 

Thanks again,

Another note from the patient:

Hi Dr. Blake,

Thanks for your last 2 e-mail. I hope you had a great time in Spain!

Here's an update on my situation. Questions in bold.
  • Feeling extremely optimistic after using the Neuropathy Pain Relief Cream + Aircast Boot for 3 days in a row. Substantially felt better. I was convinced this was going to solve my pain!
  • Tried 4 acupuncture sessions...Wasn't sure if it was helping at all but wasn't hurting. Maybe helped with the improvement.
  • Days later, the pain came back, and on strong.
    • I had some extra pressure on my feet, carrying my 6-month-old in her car-seat for maybe 15 minutes...Nothing too intense but could something this simple make my pain that much worse? Dr. Blake's comment: Leaning forward with weight can be hard on the nerves coming off your back. 
  • Over the next few days, the pain got worse, got a bit better, and then worse again. Dr. Blake's comment: Probably should be 3 days in the boot, 3 days out, alternating if the boot consistently helps. 
  • I went to an orthopedic surgeon to get another opinion... the trip was a waste.
    • He didn't have any answers/explanations for me.
    • Suggested a CT scan to see if it gives us more info. Do you think this is necessary? - Anything else it may show? Dr. Blake's comment: CT Scan shows only bone, so not sure if he was just grasping at straws. Maybe he saw something in the xray. 
    • He inserted a Metatarsal Bar below the pain area to take pressure off...Pain has been worse since.Dr. Blake's comment: I rarely ever use those, since they are difficult to place, and may put to much pressure no the metatarsals.
  • I've had pain during my last 2 acupuncture sessions (This past Tues and Thurs)...Treatment didn't seem to resolve. How many sessions should I try in total before I stop? Dr. Blake's comment: Typically, 3 sessions of acupuncture and you know if it is going to help. 
  • I've continued to use the pain relief cream + the boot with no luck. I just tried Neuro-Eze for the first time today and did not receive any relief from it.
  • I've tried Neural Flossing along with watching your video every time. This usually (but not always) provides at least some short-term relief.
  • But I'm less focused on temporarily relieving pain and more focused on figuring out what I need to do to prevent the pain from coming back at all!
    • You provided a number of great suggestions in your last e-mail. What type of doctor should I see to explore these options with? Dr. Blake's comment: Typically a podiatrist should be the primary with referrals to pain consultants if nerves are to be treated. We need to have nerve treatment to calm the nerves down. Probably need some oral med and better topicals. 
      • I no longer trust my podiatrist since it appears he mistreated my condition. (5th toe pain still present and new pain caused from injections)
      • The orthopedic surgeon I saw didn't have any insight
      • Perhaps a rheumatologist or pain medicine specialist? Or just start looking for a new podiatrist? (You've been the most helpful so far - I wish I was in your area!)
    • I've tried Lyrica - It provided very minimal relief with many negative side effects...Not worth it.
    • I have a home TENS unit - do you suggest I try that? If so, where should I place the pad(s)?Dr. Blake's comment: You need a PT to help you with application and intensity. 
  • A couple other questions:
    • Based on my most recent MRI, are we sure the doc didn't "wake the sleeping dogs (neuromas)" from the injections? Dr. Blake's comment: For the reader's sake, this patient sent me the MRI and no sign of damage was seen!! But alcohol is a destructive agent, so we are probably dealing with a deep burn, but it should get better, or surgery to explore the area, remove the nerve (permanent anesthesia), and hope for the best. I am not recommending at this time, but it is an option. 
    • Can this resolve itself on its own with time? If so, when should I expect to see progress?
      • It's almost 2 years since the original 5th metatarsal fracture
      • It's been about 10 weeks since my final set of alcohol sclerosing injections Dr. Blake's comment: The reason we need treatment is left on its own it can take months until you start to feel better. I hope November feels overall better than October. You can speed up feeling good, but we need some consistent treatment that helps. Stay with the boot, by alternating, stay with the original meds (until you have others to try). Many times injections into the nerve with just local anesthesia can relax the nerve. You can put it one inch closer to the ankle, not at the same spot. You are in my thoughts and prayers. Rich
Thank you again for your help

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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.