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Friday, October 12, 2018

Snapping Peroneal Tendons and Nerve Hypersensitivity: Email Advice

Hi Dr. Blake,

I am not sure if you remember my previous emails, but I started experiencing bilateral sesamoid pain after an ankle sprain and I wanted to update you on my condition and ask a few questions if you have time.

I did physical therapy for a month - my hips are strong now, but I still have the same pain level. I decided to get a second opinion from an osteopathic doctor/foot and ankle surgeon. He found that the outer sesamoid bone is tender on my right foot, and both are tender on my left foot. My peroneal tendons are snapping over the bone slightly on the left side (this began at the end of August when I tried Hokas and the previous doctor said not to worry) and while the intensity of the snapping motion has decreased slightly over time, I am having a lot of pain in the area of the tendons and all the way up through the muscles of the leg. He decided to put me in a CAM boot on the left side for a month. He did say that often this can't be fixed without surgery. He also talked about surgery for the sesamoids. That was scary!
Dr. Blake's comment: Nothing points to surgery for these unless MRIs show a permanent condition. Patients who irritate the peroneal tendons somehow, sometimes abnormally supinating away from their sore sesamoids, begin to feel snapping as the tendons get tight from overuse and the motion of two abnormally tight tendons causes snapping sound. You have to make sure you are not abnormally supinating, and make sure you are icing the area twice daily do remove some of the inflammation.

I asked about using sesamoid protection in the boot, but he said it wasn't necessary. However, I think I will follow your advice and make a pad out of felt.
Dr. Blake's comment: Thanks for the common sense.

I'm also having custom orthotics made (finally) that will be able to be adjusted as many times as needed.

My first question is, what can I do to maintain strength while in the boot? I'm allowed to take it off while at rest on the couch and for sleeping. Obviously, I will avoid any motions that cause the tendons to snap, but I'm worried. I will continue to do my hip exercises from PT.
Dr. Blake's comment: You are trying to relax the tendons, not strengthen them at this point. Standing flat for balance should be okay for 2-3 minutes twice daily. The tendons are irritated in different ways when the ankle is pointed or flexed too much. The most important is cross training with stationary bike riding if available. You usually can lower the seat enough to feel the less strain on the tendons.

Next, I'm still having constant tingling in both of my feet and legs (worse on the left side). My spinal MRIs are clean (very slight bulge at L4-L5 but the neurologist said it was so small they weren't sure it was there). I also had a nerve conduction test and an EEG and both were normal. The neurologist decided to start me on Effexor/venfaxaline as we both think my nervous system is just on overdrive due to anxiety. I've been on it for five days. Last night, I awoke in the middle of the night and there was no tingling for the first time in months! It did come back, but I think that is progress.
Dr. Blake's comment: I think this is a good approach. Unfortunately, those tests only show big issues, so fortunately, you have some nerve hypersensitivity but it should resolve. The medication helps the nervous system relax. You keep whatever dose needed to achieve pain/symptom relief for 2 months straight, and then you try to wean with less dose per week not per day.

So, I guess my biggest question is what can I do to keep myself comfortable while dealing with the boot? I am worried about the stress on the nerves. Should I continue contrast baths/neuro-Eze/gentle massage?
Dr. Blake's comment: Yes, please continue the gentle help from neuro-eze, gentle massage, contrast bathing, and neuro-flossing. These will help the nerves. Take the boot on and off as much as possible, since you only want the boot on when you walk. If you are wearing a boot, you have to get an Even Up on the other side, so balance the hip height with adequate shoe height. That will protect your spine.
 Do you think these approaches sound adequate (boot for peroneals, orthotics for sesamoids)? See above, and good luck. Rich

Thank you so much for taking the time to read this.

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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.