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Wednesday, March 6, 2019

Nerve Pain after Long Distance Bike Ride

Hello Dr Blake,

I found your email address after reading your blog and an article written by you in "Podiatry Today" on Morton's neuroma. I am writing to you from Australia seeking your medical opinion after seeing many specialists in Australia on my foot issue, with no real success. First a little background on my issue.

My problem started back in September 2018 whilst working overseas. I first hurt my right foot after training for a long distance bicycle ride. The initial symptoms were tightness in my calf, sole of foot and some heel pain. The heel pain would be shooting pain on the inside of heel whenever my foot was dorsiflexed. Over the following three weeks, whilst standing in my job, my condition worsened with the onset of pins/needles throughout the sole of my foot. At the end of a typical work shift my whole right foot would be completely numb and tingling. The GP's that I first saw thought it was plantar fasciitis and prescribed me anti- inflammatories which provided some relief.  I also saw a podiatrist who moulded me a set of orthotics with little improvement noticed.  After three weeks I returned to Australia in October and sought further investigation.
Dr. Blake's comment: There are 3 sources of pain: mechanical, inflammatory, and neurological. The cause of your pain was mechanical (the long distance bike ride), but the symptoms are all neurological. This is like overstretching the calf, and pulling too long on the sciatica nerve, and having the calf pain intensify. You have to treat this neurologically at first with treatments that help nerves. then work on the mechanics, and any inflammation that has set into the tissues.

Since I have been back in Australia I have seen the following specialists:
  • Neurologist (Nov) - performed a nerve conduction test, which was inconclusive, apparently quite often this happens with people over the age of 40.  Had an MRI (report attached below) which showed a thickening of the medial planter nerve throughout the mid-foot course involving up to 8 cm in length.  The Neurologist concluded that I had Tarsal Tunnel syndrome, informed me that surgery was my only option and referred me to an Orthopaedic surgeon.
          Dr. Blake's comment: Yes, there is 1-5% of almost any injury that has a surgical solution, but
          that is not where you start. Hopefully, you never have to go down that route.
  • Orthopaedic Foot Surgeon (Nov) - the orthopaedic surgeon said that I did not have tarsal tunnel syndrome as the thickened nerve was not in the tunnel.  He was reluctant to operate and advised me to take three months of rest and see if my condition improves.
  • Podiatrist (Dec) - visited a podiatrist who concluded that I may have medial calcaneal nerve entrapment and/or Baxter's nerve entrapment.  Advised me to keep wearing my orthotics.
  • Orthopaedic Foot Surgeon (Feb) - condition had improved after three months of rest, but still only limited function. Surgeon would not operate and referred me to a Anaesthetist/Pain Specialist.
       Dr. Blake's comment: When you irritate nerves, they can take a long time to relax, so most of this
       advice is good. It is using only rest as the number one treatment for nerve pain, but not bad
       advice. Glad that they sent you to a nerve guy (called pain specialists).
I am now awaiting an appointment with the Pain Specialist on March 27th.  My current symptoms are the following:
  • Can walk okay, but after one mile or so start to experience pain in the sole of my foot 4/10 (feels like a stone in my shoe). The pain extends from where the heel ends, along the mid-foot section. Dr. Blake' comment: Do not push through this pain. Do you guys have Uber down there?
  • Tightness in calf has disappeared. Dr. Blake's comment: Great, that means some of the neural tension is improving. Has the heel also resolved?
  • Cannot walk down stairs properly as the dorsiflexion of my right foot causes a shooting pain on the inside of my heel. Dr. Blake's comment: Just answered the above question. Remember the sciatic nerve, branches of the big nerve are irritated on you, is pulled too much right now with ankle dorsiflexion, straightening the knee, and bending over at the waist. Try to go downstairs leading with the bad side, and then lowering the good side to the same level. That is usually the best. Down with the bad, up with the good is the mantra.
  • Flat surfaces are okay for a mile or so, but inclines uphill or downhill really take a toll on my foot quite quickly. Dr. Blake's comment: Stay on flats right now as the neural tension resolves. It is never a fast process. Sorry.
  • Sometimes when I stand in one spot for an extended period my foot turns red.  Podiatrist was initially concerned that I may have the beginning of CRPS and encouraged me to keep walking. Dr. Blake's comment: This is called vasomotor insufficiency where the skin and soft tissue are influenced with nerve spasticity. This is part of the neural tension also. Nerves love motion, and not prolonged stretching. They do not like certain positions, so keep moving is a good thing, or at least finding comfortable sitting or laying positions when you can not move.
  • Still wearing orthotics which help a little.
  • Currently on Lyrica 150mg to ease pain on the days I walk more. Dr. Blake's comment: Typically I wonderful nerve treatment if you can tolerate.
Am I a candidate for Radio Frequency Ablation, cortisone injections, or alcohol injections?
Dr. Blake's comment: Unless someone can tell you that a neuroma, or entrapped nerve, is a constant trigger for the pain, it is best to not risk irritating it for now. As your symptoms get better, and one spot on a nerve remains super sensitive, then some discussion is in order. I doubt you will need these, but I am of course not sure. I would not do anything invasive to speed up the treatment. With nerves, that course of action tends to irritate more than help.
  Is there any value in having a diagnostic injection around the medial calcaneal nerve or Baxter's nerve to see if the shooting inside heel pain is relieved when foot dorsiflexed?
Dr. Blake's comment: Local anesthetic on an inflamed nerve could help, and you may need to do several over 3-4 weeks. That being said, it goes against my better judgement. Do this for me. Have you knee straight and then dorsiflex the foot, you should get nerve pain. Now, bend the knee to ninety degrees and then dorsiflex the foot. If there is no pain now with that change in position, it is most likely an irritated nerve, not an entrapped nerve (which should hurt both ways). It is another finding and for sure not conclusive. What I have not had you say is that the MRI showed a possible nerve entrapment in the heel with intense swelling, etc. I have also not heard you say anything about a low back MRI since this can be all coming from your back.

 Could I have a nerve entrapment that might be relieved with Radio Frequency Ablation?
Dr. Blake's comment: This is not a procedure I have any experience in. Start doing traditional treatments: neural flossing, Neuro-Eze or like products, get the Lyrica dose up to normal amount, add Cymbalta if you can tolerate, avoid positions that irritate the sciatic nerve, see a physical therapist skilled in nerve problems, try topical compounding meds that have Ketamine, get your low back pain eval, look into foods that irritate the nervous system, and get supplements that calm it down. Most of this is in my blog also. I hope I have been somewhat helpful. Rich
Be kind to yourself, and do not rush into treatments, meditate daily, acupuncture can be of great help.

I have researched a lot online and there is very little information about enlarged nerves, besides Morton's Neuroma.  I really don't wan't to be on painkillers the rest of my life and refuse to believe that this is the end of the road for me.  I recognise that I may never get full function back, but am searching for a procedure that could improve my condition a little. In Australia there does not seem to be any podiatrist surgeons that specialise in my condition, or at least I don't know who they are.  The Pain Specialist is currently my next avenue for help.  Any feedback you could provide would be greatly appreciated.


The Patient then responded:

Hi Dr Blake,

Hello from Down Under. Thank you so much for your quick and detailed reply.  I have already actioned a number of your suggestions, like taking supplements to calm down the nerve (Vitamin B12) and ordering Neuro-Eze to apply to the sole of my foot.  I will also explore acupuncture and physical therapy.

To answer some of your questions:

  • Heel Pain - For over a month now I have been going down the stairs by leading with the bad side and lowering the good side second, just like you suggested.  Then today I decided to try and walk down the stairs normally, so I could report back to you on my progress.  Good news, I managed to walk down the stairs with only minor discomfort which was a big improvement from a month ago. Still have tenderness around the inside of heel and the arch of foot though.
  • Dorsiflexion Test - I performed the straight leg and bent knee dorsiflexion test like you suggested.  In the straight leg position I felt no pain, however I have lost about 20% range of motion when compared to the other foot. I'm pretty confident that if someone pushed on my foot it would have elicited some pain as it did before. Dorsiflexion in the bent knee position hurt.  Is nerve entrapment still a possibility? Dr. Blake's comment: Yes.
  • Explore lower back possibility - When I see my specialist next week I will ask him for some imaging on my lower back, as you indicated it may be the source of the pain.

What I didn't mention in my first email was some other symptoms that presented when I first hurt my foot 5 months ago after the bike ride. The tightness in the calf was predominantly in the top outer side portion, combined with big toe tingling and sensitivity.  In fact, whenever I experienced the shooting pains through the sole of my foot, the big toe would end up throbbing.  After researching quite a lot I believe my initial injury may have been a sprain of the Flexor Hallicus Longus muscle, apparently a common injury amongst ballet dancers and bike riders. If the FHL was inflamed throughout the foot, could this have led to the medial plantar nerve enlargement ? Dr. Blake's comment: For sure, and that should be calming down. 

Thank you again and look forward to your reply.

P.S. We do have Uber down here! 

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.