CRPS and Low Dose Naltrexone

     CRPS stands for Complex Regional Pain Syndrome. It is a sympathetic overload of the nervous system set off with fairly minor injuries. One of the key observations is a distinct change in color of the injured side, and pain out of proportion to the injury. Basically, if no one can explain why your foot looks like that or why your pain is so high, you may have CRPS. The treatments are many and successful, but must be done soon to relieve the tension in the nervous system. The article below talks about a medicine that can help in the long term treatment. 

https://urldefense.proofpoint.com/v2/url?u=https-3A__www.medpagetoday.com_opinion_pain-2Dpoints_99457&d=DwICAg&c=YFhW2PYwN3hsZhoCqLOPHsIEIPQ6qDXkZ40AlEYUG9c&r=NCqorp6Dhthq3VH41iV8dOc-_tN9z0t9gOAVzfIO-jQ&m=15FPT7Mm-mHD6R3vQKXy9kN6zkD5cqB-LVW4xS4SHFYOcw6efBsrn8N_0NjZHeyB&s=C0kYTOiln06q816xdwfN2WzCZCyb9_E65oZH9aHikw8&e=

CRPS following foot injury: Email Advice

Hello I’m recovering from two tendons and stress fractures in both my sesamoids.  I’ve also been diagnosed with CRPS which for me involves significant swelling and temperature changes in my left foot.  I’ve finished almost four months of immobilization and am starting to walk around in my insoles and orthopedic shoes.  My foot turns hot and cold though.  The injections I received for CRPS seemed to have resulted in little change in these symptoms.  Walking starts to really hurt after not too long and I fear I’m damaging my sesamoids again.  is there any way to tell?   How much pain do you have when you start walking and how long does it last?  Should you just stay off of it longer?  Any thoughts on CRPS?  Also what are your thoughts on other treatment modalities to boost recovery?  What about prolozone injections?  PEMF?  I have a bone stimulator.  Thanks


Dr. Blake's comment: CRPS is a complication from chronic pain or an acute injury. The changes in your foot is called vasomotor insufficiency and could mean that the tissue is not getting enough blood to heal. Typically sympathetic blocks and oral meds can help considerably. Do you know what type of shot you got? Movement is crucial, as the immobilization is terrible for CRPS. Make sure the sesamoids are protected with orthotics and dancer's pads, and you will have to tell me what tendons you hurt. But, they should be protected with taping and bracing if possible to decrease the pull of the tendons. If you can start contrast bathes at 1 minute hot (100 F) and 1 minute cold (60 F) for 20 minutes with it feeling better, try it since it is a great way to get the circulation moving. Acupuncture is also helpful. See if there are any neuro physical therapists in your area to consult. Your team should be podiatrist or foot orthopedist, neuro physical therapist, acupuncturist, and pain specialist to do the sympathetic blocks and prescribe oral meds to calm nerves down like Lyrica and Cymbalta and nortryptyline. Get the foot and ankle moving as much as you can without flaring it up. Consider the Curable app and NOI flash cards. Consider Quell (I think that there is some money back guarantee). If you can get Calmare treatments, that would be great. Tons of things to do.  Hope this helps some. Rich

Followup on Foot Fracture and Nerve Pain

This patient broke her toe and developed severe nerve pain afterwards. This post is also included on her original post of 4/5/18. This is a wonderful example of how active we have to be in our treatment to get the right healing plan working. 

Hi Dr Blake,

I wanted to give you and your blog readers an update...

I was worried after fracturing my toe (4th toe on left foot) I was developing CRPS because I have other nerve issues.  I fractured my toe on Feb 2 and the pain just got worse.  My foot turned ice cold blue and was like that for over a week plus my fracture wasn't healing and I was having shooting nerve pain/burning in my foot.  I am wearing a boot and have a scooter.  I did the following to try to heal my foot (which I found some of it on the blog from another reader):

• Went to a new anesthesiologist who just moved here from Cleveland Clinic and specializes in CRPS.  I was lucky to get a next day appt with her.  She was very nice and felt that it wasn't CRPS.  She did give me Cymbalta - which I didn't take since I am sensitive to medication.
• Bought a used bone stimulator and used it twice a day (based on recommendations from several doctors - including Dr Blake)
• Light massaging to increase the blood flow
• Putting leg up when sitting or lying down
• Started taking (all of these without fillers) each day:
• 1200 mg of R-Alpha lipoic acid
• 1200 mg of NAC
• 2000 mg of vitamin C (powder to mix in water with cranberry concentrate)
• 600 mg of Calcium Citrate (powder to mix in water with cranberry concentrate)
• 5000 mg of vitamin D
• Magnesium citrate
• I am taking some herbs as well
• Stinging nettle tincture (without alcohol)
• Horsetail (without alcohol)
• Comfrey tincture rubbing on skin over fracture and applying DMSO on top for better absorption.  I purchased Heiltrophen on Amazon - the bottle and dropper are glass which is important because DMSO absorbs everything.  I applied with clean hands and washed them afterwards without soap.
• I tried Dr Christopher's Syrup and Ointment for bone and tissue repair a friend recommended.  Tastes and smells awful.  Lots of stars on Amazon but I couldn't stand it to take it consistently.
• Mirroring 
• My friend let me borrow a mirror so I am doing some mirroring exercises I found on youtube.
• Went to Orthopedic surgeon (I wanted a second opinion in addition to my very good podiatrist just because the foot wasn't healing).  I was lucky that the orthopedic doctor for the feet of the US ski team had an appt.  Really nice guy - he just confirmed what my podiatrist had recommended)  He said I needed to be off the foot for 6 weeks and gave me a clearance for work.

So I am happy to say after 6 weeks on my protocol,  that the pain is almost gone from my foot.  I don't have the shooting nerve pain in my big toe and the burning is less.  I am able to walk very short distances without the boot.  It isn't keeping me up at night.  It looks like I am on a positive trajectory.  I think it will still be a while before I really feel comfortable walking longer distances and doing my normal routine but at least, it is getting better.

Thank you so much Dr Blake for your support and help.  

Complex Foot Injury: CRPS??

Dear Dr. Blake,

     The gentleman from Mountain Family Products referred me to you because my podiatrist recommended a bone stimulator.  I didn't want to wait for the insurance to pay some time next month because I am concerned about my work and getting healed in a timely manner. 

   

   On February 2, I stubbed my toe on the way to the airport for a business trip in Europe.  I was sort of healing the month of February when I re-injured it about 3 weeks ago and now the pain is through the roof.  Nothing seems to help.  I went to my osteopath first and he told me to get metal inserts for my tennis shoes.  That didn't help.  Then he did a cortisone shot on March 12 that lasted about 4 days and the pain came back. 

Dr. Blake's comment: This is the first clue about what will help. We know the pain can be eliminated by the shot, even if temporary. What did he inject? The MRI revealed bone edema at the 4th metatarsal. Did you stub the 4th toe? 

  Then he did a nerve block and it didn't help.  

Dr. Blake's comment: Was the nerve block in the same spot? 

     Finally, yesterday I saw a podiatrist who gave me an insert for my shoe, told me to take Calcium, Mag, D and some neuro vitamins like Metanx - which I happen to have.  I have a scooter I am using since last Friday to keep as much weight as possible off the foot.  I tried on a boot and it was too painful. The doctor also recommended a bone stimulator and using some ice packs no more than several times a day for 20 minutes or less.  He also gave me tramadol which didn't help.  I tried ketamine cream and that didn't help.  I started something called Dr. Christopher's tissue and bone ointment to see if that will help.

     I saw that Dr. Axe mentioned the following:  L-lysine, bromeliad, vitamin k as supplements for bone bruises.

Dr. Blake's comment: There are 3 types of pain: mechanical (just as a break), inflammatory due to the healing response, and neuropathic due to nerve injury or nerve protection (hypersensitivity). You are succeeding in mechanical means to lower the pain, some inflammatory should be helpful. It does not sound like neurological treatments like ketamine help topically, but you must have some neurological component to your injury. You may want to try oral pills like Gabapentin. 

     I have an autoimmune neuropathy from a toxic exposure last year.  My feet already burn and my nerves are hyper anyway.  The pain is very agitating for me because the burning isn't under control.  My neurologist is trying to get IVIG infusions for me.  The pain from the foot is radiating all over my foot and up my leg.  I think part of that is the way I have been walking - or limping around.  My feet have been burning since last October and sometimes I don't know if it is the SFN or the foot.
Dr. Blake's comment: So, have they worked you up for Complex Regional Pain Syndrome? You are set up for it with the nerve issue already. You create a 0-2 pain level with your scooter, you may need Sympathetic Blocks, IV Ketamine, or Calmare Pain Therapy. You may just need Lyrica or some cocktail that cools the nerves down. How does it feel to rub in creams like Ketamine? 

I guess I am just wondering if there is anything on your blog or on the internet that may help me in my healing process.

Dr. Blake's comment: Typically, while docs work on the nerves, PTs and acupuncturists help with the pain, and deciding what you can and can not do. See my blog on CRPS to see if that makes sense. See a neurologist if it does. Try to find a PT who understands CRPS because it is important to honor the pain at times and push through the pain at times. 

I am enclosing the notes from the MRI. Does not say much!!

Thank you in advance for any direction.

Kindest regards

And the patient's response:

Dear Dr. Blake,

I posted my responses to your questions on the blog.  Thank you very much for your responses and insight.    I am going to have a ketamine infusion on Monday.  My neurologist says one infusion each month is enough so I will see how I tolerate it.  My foot was healing ok until I decided to do a little dance to make myself happy - now I wish I had just stayed morose... Anyway, I am doing meditation, self-hypnosis, 2000 mg of C divided during the day, I have glia modulators - LDN and Nortriptilyne.  I am weaning my self off the lamotrigine.  I am hoping to get a trial of IVIG in the near future.   I went ahead and bought the bone stimulator and it will arrive tomorrow.  I couldn't wait until the middle of next month when the insurance will kick in.

I am going to try the nerve flossing and I have a mirror set up for the mirror therapy (I saw it on youtube)  I also called my PT who will call me back next week.

I am trying to cover all my bases because I have a very real possibility of losing my job since the autoimmune neuropathy has been going on for 8 months now.

Anyway, thank you again for all your help.  Greatly appreciated.

Dr. Blake's response: I am so happy and great faith you will get the nerves calmed down. Go to NOI group website and order their extremity cards. It will make sense when you see them. You can get sublingual Ketamine for flare-ups. Let me know 2 weeks after the Ketamine infusion, and for our readers, get as much information on exactly what the infusion center will do: dosage, mixture, time of drip, etc. Good luck Rich

Another Response from the patient:

Another question...

How often can I use the stimulator?  My doctor suggested 20 minutes once a day and any more than that would be a waste.  Ross - at mountain family - mentioned that he heard of some patients using it 20 minutes with a 12-hour window between treatments.

Thank you

Dr. Blake's comment: Yes, I would do the 20 minutes twice a day for the first 4 months, and then you can cut it down to once a day. 

The Response from the patient:

Rich

Thank you for your message and the information.   I had the ketamine infusion and it was one of the worst experiences of my life.  I will go back and find out the specifics.  I had horrible hallucinations and was very nauseous.  I could hear the nurses laughing and talking the whole time.  It didn't help at all and in fact, I felt worse probably because it traumatized me.   I think that it is best to go to a clinic that specializes in ketamine.  I haven't given up on it but I think that it's important to find the right place.

I am going back to the podiatrist tomorrow and I found a pain management physician who knows about CRPS and she actually had an opening on Thursday this week.  I am going to order the R-alpha lipoic acid and the NAC to get started on them.  Unfortunately, I will have to cancel a very important business trip and I am nervous that will cost me my job.

I will look into ordering the cards.

Thank you

Dr. Blake's comment: I am so sorry for your bad experience. Infusion Centers in general are peaceful, calm, no noise, so you were definitely not in the right place. Yes, you need one familiar with the nuisances of Ketamine. I have attached a reference for dosing for you. Please find out what the dose they gave you. You can see from the article that the range is from 1 to 4.5 mg ketamine/kg of your weight. It would be important to know if you got minimum or maximum dose as your loading dose based on your side-effects. Was there someone there with you to hold your hand? Important. Were the lights dim in the room? Important. Quiet!! Very Important. 

https://reference.medscape.com/drug/ketalar-ketamine-343099

The patient's later response:

Hi Dr Blake,

I wanted to give you and your blog readers an update...

I was worried after fracturing my toe (4th toe on left foot) I was developing CRPS because I have other nerve issues.  I fractured my toe on Feb 2 and the pain just got worse.  My foot turned ice cold blue and was like that for over a week plus my fracture wasn't healing and I was having shooting nerve pain/burning in my foot.  I am wearing a boot and have a scooter.  I did the following to try to heal my foot (which I found some of it on the blog from another reader):

• Went to a new anesthesiologist who just moved here from Cleveland Clinic and specializes in CRPS.  I was lucky to get a next day appt with her.  She was very nice and felt that it wasn't CRPS.  She did give me Cymbalta - which I didn't take since I am sensitive to medication.
• Bought a used bone stimulator and used it twice a day (based on recommendations from several doctors - including Dr Blake)
• Light massaging to increase the blood flow
• Putting leg up when sitting or lying down
• Started taking (all of these without fillers) each day:
• 1200 mg of R-Alpha lipoic acid
• 1200 mg of NAC
• 2000 mg of vitamin C (powder to mix in water with cranberry concentrate)
• 600 mg of Calcium Citrate (powder to mix in water with cranberry concentrate)
• 5000 mg of vitamin D
• Magnesium citrate
• I am taking some herbs as well
• Stinging nettle tincture (without alcohol)
• Horsetail (without alcohol)
• Comfrey tincture rubbing on skin over fracture and applying DMSO on top for better absorption.  I purchased Heiltrophen on Amazon - the bottle and dropper are glass which is important because DMSO absorbs everything.  I applied with clean hands and washed them afterwards without soap.
• I tried Dr Christopher's Syrup and Ointment for bone and tissue repair a friend recommended.  Tastes and smells awful.  Lots of stars on Amazon but I couldn't stand it to take it consistently.
• Mirroring 
• My friend let me borrow a mirror so I am doing some mirroring exercises I found on youtube.
• Went to Orthopedic surgeon (I wanted a second opinion in addition to my very good podiatrist just because the foot wasn't healing).  I was lucky that the orthopedic doctor for the feet of the US ski team had an appt.  Really nice guy - he just confirmed what my podiatrist had recommended)  He said I needed to be off the foot for 6 weeks and gave me a clearance for work.

So I am happy to say after 6 weeks on my protocol,  that the pain is almost gone from my foot.  I don't have the shooting nerve pain in my big toe and the burning is less.  I am able to walk very short distances without the boot.  It isn't keeping me up at night.  It looks like I am on a positive trajectory.  I think it will still be a while before I really feel comfortable walking longer distances and doing my normal routine but at least, it is getting better.

Thank you so much Dr Blake for your support and help.  

CRPS: Email Advice

Hi Dr. Blake,

I am hoping you can offer us some advice as we’re getting pretty desperate.  My son (13 years old) suffers from CRPS.  He has had pain for over 5 years, but the severe pain and hypersensitivity (and other symptoms of CRPS) for the past 2 1/2 years. We have tried prescription pain medications, lidocaine infusions, traditional Chinese remedies, physiotherapy, light therapy, psychology, and most recently neuroprolotherapy (he went into shock).  He is barely sleeping, attending school less than half time and losing touch with friends, etc.  (spiralling downhill and I worry about depression).  I know you ask people to be concise but I’ve attached a description if you have time to read.  Any advice you can offer would be VERY VERY mush appreciated.

Thank you so much,

Dr Blake's comment: 
     Thank you for sending the summary that I read. I am so sorry for this injury. Definitely see if you can get the 10 treatments of Calmare Pain Therapy in the nearest center. I am sure it is not 100% successful, but it is non invasive, and has great successes. Neuroprolotherapy seems very good, but this is with sugar water injections only. I am not familiar with the Ozone injections that gave your son his problems. Find someone for normal neuroprolotherapy if the Calmare gives suboptimal results. Every good pain management specialist that treats this has a topical cream they like. This is so important to find one that you can gently rub in to the tissue for desensitization three times a day. This has to be a daily fix no matter what else you are doing. I guess IV Ketamine Infusion is next, but I am not sure at what age they would start at. I sure hope this helps some. Rich

Another Video on Calmare Pain Therapy: CRPS and other forms of severe pain can benefit

http://www.calmarett.com/pain/howitworks.html

Complex Regional Pain Syndrome: Email Advice

Dear Dr.blake

Hope you are doing well .

Just wanted to update you regarding the progress of my algodystrophy (that struke me after my sesamoiditis ) Dr Blake: Algodystrophy is another name for complex regional pain syndrome.

As this might help other people who are in pain or experienced RSD symptoms.

-          I have followed your advice and went looking for calmare therapy – couldn’t find any around since I live In a small country – I found one center who have a PBK “Italian electro machine”

The owner claims that he have amended it’s program to do the effect of calmare/ since I had no choice I tried it /

To my surprise it worked wonderfully. And after only 6 sessions  . my pain was 50 % less . now I have high hopes , I think by Christmas my aldodystrophy will be gone  "6 month after the discovery of the RSD”

So I definitely recommend calmare or alternative calmare ,  since I have tried acupuncture and other  it helped only at first.   Dr Blake: Calmare works permanently on some and some seem to need booster sessions occasionally. Calmare is an electrical current and does not involve anything invasive, like IVs or injections. 

-          My main problem is that after I heal from the main full leg pain I would still have issues with my fingers and sesamoid bones ,  because of the non bearing issue – what shall I do or start doing to improve mineralization in

That area. And as per your  experience how much time it would take to get back to normal in that area after RSD is gone. I am seriously desperate to go back to normal and willing to do anything required.

Dr Blake's comment: This patients has had very bad disuse atrophy of the bones from months of non weight bearing and inactivity. The treatment needs to be directed towards gradual weight bearing. There is no time lines that I know. Set benchmarks on what you can do this month, and reset them in next month. By gradually increasing walking, biking, elliptical, core work, etc. the strength will come back, but never at the pace you want. 

-          I have another issue , with orthotics ,  I have tried a dozen with a collection of shoes . and paid of fortune on these . still I have a problem that when I stand more than 20 minutes in these ,  I feel like I have been standing all day, and

I have to sit for a while before I can walk pain free. Also walking for more than 15 minutes give the same feeling.

I got some weird pain till the point that I thought I have RSD in the second leg . but I don’t /

I know orthotics are not supposed to be 100% comftable and that they changed our gait .   but this is really frustrating and I feel it in both legs , if I have to wear orthotics for a year or so , I really need to find a solution.

An orthopedic doctor told me that my calfs became weak and there’s too much pressure on the feets and heels= he said that  after a year of wearing orthotics my gait changed and my muscles got weaker and that I need to do stationary biking – I cannot do biking now and waiting for a month or so when RSD is fully gone.

Is that kind of pain and discomfort normal when wearing orthotics ,  what can I do to reduce it ???

Dr Blake's comment: All you can expect orthotic devices to do is protect the joint that was injured. Your symptoms seem to be bone fatigue and muscle fatigue and nerve irritability. You seem to be on the right path to restrengthen. Find the most comfortable orthotic you have and experiment with more padding, more arch support, more dancer's pads, etc. See if anything mechanical really improves the tissue threshold you are experiencing now. 

-          Regarding Vitamins .  the doctor told me to reduce smoking and it helped . he gave me raw honey since he said some new researches revealed that RSD is linked to a deficit in the immune system.

And I am taking multivitamins with extra calcium and magnesium.  For how long do you think I should continue taking vitamins ? ? is it ok to take for long months or years or this could be harmful.

Dr Blake's comment: I think that you should sit down with a registered nutritionist and attempt a game plan to reduce inflammation, improve nerve and bone health, and strengthen your immune system. 

Sorry for the long email.

I thank you a lot for your support and wish you happy holidays . Jesus bless for being such a hope for many people around.

Dr Blake's comment: Thank you, I have been so blessed by God that it is hard to ask for anything else. Merry Christmas to you. 

Nerve Pain: Email about Calmare and MRI

This is an email that I received after letting one of my patients know that Calmare Pain Therapy for neuropathic pain was finally being offered in the San Francisco Bay Area by an MD Dr Susan Gutierrez in Danville and San Ramon areas. 

http://www.yelp.com/biz/susan-gutierrez-md-san-ramon

Hey Dr Blake, thank you for thinking of me.  Have you had patients experience success with calmare pain therapy? (the success of one patient's treatment with Calmare has a link below)

Here is the post from my one patient so far. 

http://www.drblakeshealingsole.com/2014/03/calmare-therapy-rising-star-for-nerve.html

I am also sending all my nerve patients to Dr Lee Wolfer now if I can get approval/insurance coverage to see her. My other favorite docs are Dr Michael Moskowitz and Dr Michael Savella in Marin County. Thanks to your recommendation. 

  i'm asking because overall the CRPS pain is doing much better, thanks to dr. wolfer's dextrose nerve blocks since feb of this year..  these are done with ultrasound guidance.  i've had blocks on my femoral nerve, sciatic nerve,  sapenous nerve, and the most stubborn, oldest pain site - the tibial nerve. lee actually would love if you called her.  she believes she can help some CRPS patients if you are open to talking with her, that is.

Dr Blake's comment: Dr Lee Wolfer is an amazing pain specialist. Here are several links referring to her.

http://www.drblakeshealingsole.com/2014/05/neural-prolotherapy-potential-help-for.html

http://www.drblakeshealingsole.com/2014/05/complex-regional-pain-syndrome-email.html

i had a classic prolo injection into my big toe joint about two weeks ago. it helped quite a bit.  i will most likely need a few more as well as a repeat tibial nerve block.  man, this condition is stubborn.  as i wait for an appt with lee, i continue to do everything else:

accupuncture

homeopathic remedies with accupuncturist who does muscle response testing (this is fascinating stuff!)

PT exercises to the point i can bear the pain

supplements - more than i can bear at times; pill fatigue is real

bike or swim 

anti-inflammatory diet and moderate paleo

contrast baths

In regards to my left big toe joint, i do the spica taping and cluffy wedge daily.  and i walk in my orthotics all the time except when going to client meetings. i continue to scan the web for womens shoes with removable footbeds.  my foot doesn't fit well into a lot of the brands.  so i continue to search, order, and return shoes.

anyway, this is a long update to say i'll hold off on seeing dr. gutierrez.  but i will post her name on the facebook CRPS support group.  should i get to a point where i was pre-february 2014 then i will definitely make a consultation.  i'm spending so much money (~ $1,200/month easily cash) as it is.  the thought of adding another cash consult/procedure overwhelms and stresses me even more.  not to mention the added coordination and travel.  i've tried four PTs, several MDs, three accupuncutirsts before landing on the multi-disciplinary team i have now.

thanks again so much for thinking of me.  i need to make an appt with you after i get my hands on my some shoes that fit my feet. did my MRI show anything besides big toe joint OA and inflammation?

hope all is well with you,

Here is the image of the left big toe joint on MRI. The sensor is along the second toe side. The fluid in the medial side of the first metatarsal signifies substantial bunion joint arthritis. No wonder the nerves around the big toe joint get upset and painful.

This MRI of the left foot focuses on the inflammation in the 3rd intermetatarsal space where a Morton's neuroma may reside. Definitely a cortisone shot can calm that down and prevent the nerve triggering.

Another image of the big toe first metatarsal head. The white within the bone is not healthy. The sensor overlies swelling in the space between the first and second toe which irritates the deep peroneal nerve in that area. This is the second trigger of left foot nerve pain.

Here the image highlights the first metatarsal bone swelling on the bunion side of the joint. The swelling is plantar (bottom of the foot), making weight bearing hard, and making the spica taping, dancer's padding,  Cluffy Wedge, and Hannaford orthotic devices crucial.

http://www.drblakeshealingsole.com/2013/02/sesamoiditis-and-hallux-limitus-email.html

This last image also highlights all the intense swelling right where the intermetatarsal nerve runs. This can produce Morton's neuroma symptoms without actually being a neuroma. Cortisone injections are considered for this.

And here my patient's response: 

very thoughtful response, as always, dr. blake.  i especially love how you educated me (and all the other readers of your blog) on what my MRI means.  

a few quick names i want to pass along.  srinika is my acupuncturist and nutrition/supplement advisor.  she did a nutrition response testing on me and i was fascinated by the results:

1. my body needs to detox itself before it can absorb any supplements
2. the toxins in my system are due to a category called air pollution.  see her blog entry --> http://srinikahealing.com/atmospheric-spraying-destroying-health/
3. my body responds to the homeopathic remedies!  my skin started itching as a result of the toxins trying to escape my system.  
4. the homeopathic detoxification remedies along with weekly acupuncture are extremely helpful in improving pain

this is her site:

http://srinikahealing.com/nutrition-response-testing/

interestingly enough, lee used to work in the same office as lee years ago!

i also like my PT, rachel feinberg, in palo alto.  she has 13 years experience in CRPS and tailors a functional restoration program for each patient.  link is below, which also has her CV.

http://www.feinbergmedicalgroup.com/#!our-providers/vstc1=rachel-feinberg

still shoe searching!

Diet for Reducing Nerve Pain

http://www.rsdrx.com/four_f's_diet.htm

Nerve Pain and the Loss of Right Left Discrimination

I was just purchasing the laterality cards for one of my patients who does not use the internet from noigroup.com when I saw/remembered that they have an app. So I downloaded it and thought I would spread the word. When you have nerve pain in your foot you can lose the ability to discern if you are looking at your right foot or left foot. It is the brain trying to avoid pain, and as this process of avoidance gets rooted in your nervous system, it is hard to reverse. Laterality flash cards demonstrated by the app below, and purchased for around $50, can be for feet, hands, knees, etc. Depends where the nerve pain is. It is extremely helpful at preventing the nerve pain rewiring that is devastating to many. It is part of a process called graded motor imagery. 

                               Is this the right or left foot?

https://itunes.apple.com/us/app/recognise-feet/id500548834?mt=8

http://www.drblakeshealingsole.com/2012/12/crps-initiation-of-flashcards-for.html

Severe Foot Pain from Trauma: Email Advice with Patient Response

Dr. Blake,

Thank you so much for your blog.  It is very informative and helpful.  It is easy to see that  not only do you love what you do, but how much you truly care about people too.

I have a situation in which the aftermath of injury is more complex than the initiating injury.  My toddler pulled an object off the dining table and it did a nose-dive into the top left of my foot, below and between the fourth and fifth toes.  I immediately went to my bed and hollered for ten minutes straight.  I never knew such pain.  This was followed by an attempt to walk, which I soon gave up and dropped to hands and knees in order to get around.  Unfortunately, my foot had already borne the weight of heavy limping in places it’s not supposed to.

The beginning was really tough-the first two weeks of healing were like having the flu, being crashed in bed most of the time and sleeping as much as possible.  Physical response included extreme fatigue, severe swelling, pain, severe discoloration (deep purple/bright red/pale), throbbing, severe skin temperature fluctuations, inability to walk or tolerate pressure (not even a bed sheet!) A few weeks later I noticed a soft, squishy lump inside the bottom of my heel that made me feel weird, but when I tried to check it again, it was gone.

Dr Blake's comment: This may be what is called neural over-reaction or Complex Regional Pain Syndrome. 

Due to certain circumstances, the medical care I received at the start was not very adequate.  No one knew what happened to my foot and I heard different things from different doctors.  Even the same doctor told me at one visit, while looking at the x-ray, that my foot was broken right “there” (AAYYY!) and at the very next visit said no, it’s not broken and there’s no evidence that it ever was (what evidence was he looking at??)  I was completely off my foot for about 10 ½ weeks due to pain and swelling, but did manage to pull my over-sized foot out of the aircast, stuff it into a tennis shoe and hobble without crutches before he released me.  It was around a similar time that I could (finally!) place my bare foot (with no weight) flat on the ground.  This was around three months post-injury.

Six months later I still had a constant limp, swelling, discoloration, pain, wrong temperature (usu. too cold), lack of function, stiffness, tingling nerve, and I went back to the doctor (different one this time).  I’ve been working with her now for about four months.  I’ve seen some improvement first in function and circulation, second swelling, and improvement in pain is much slower going.  My primary pain points are the heel, arch, across ball of foot, sesamoids and big toe.  Swelling always causes pain to increase.

Over the past thirteen months my diagnoses have been described as:  possible bruised bone, no one ever agreed on whether or not my foot was broken, sesamoiditis, callus, plantar fasciitis, varicose veins, medial hallux neuralgia, IT band syndrome (both legs, from limping too long), and lumbar strain (for which I had to go to another dr.)  Treatments have included a short aircast x 5 wks, Powerstep orthotic (all the time), steroid pack, several applications of Unna boot, a below-knee compression sock, and PT including iontophoresis and Graston technique (left foot and both legs), and of course icing (with a cold pack). Back treatment also included some anti-inflammatory meds.  A flare-up of anything (left foot-legs-lower back) has the potential to aggravate the whole system.

So here are some of my thoughts-
Will I ever be able to run, jump, tiptoe and stand in the shower?  Return to normal function?
Will I ever be mostly pain free/able to bear full weight (esp. sesamoids, big toe, and across ball of foot)?

Why do I still have pain and swelling?  Occasional swelling inside the compression sock?

Can I get orthotics for my ice skates if I ever make it back onto the ice (non-competitive)?

How long do I stick with PT?  Current doctor?  Get a second opinion?  Which medical discipline?

What can I expect long-term?  Will my foot ever feel ‘normal’ again?  How do I exercise?

How do I keep the system in balance and not aggravate opposing-injury cycle?

If I lived anywhere nearby, I would definitely set an appt. to see you.  I am truly blessed to have found your blog and thank you for any input you are able to give me.

Marie (pseudo name)

attached are a couple of pictures

The swelling and redness are common parts of some presentations of CRPS. It is called vasomotor insufficiency. 

Dr Blake's comment:

     Marie, I am so sorry for your problems. It sounds like you have a version of Complex Regional Pain Syndrome. There are so many treatments for this, and you need to be in the hands of a podiatrist and pain management specialist in your area who are knowledgable about this disease. If that diagnosis is confirmed, my blog is full of many ideas on treatment. I hope this is helpful to you. Rich

http://www.drblakeshealingsole.com/search/label/Complex%20Regional%20Pain%20Syndrome


Marie responded several weeks later: 

Dr. Blake,

Thank you so much for your reply.  I saw a local pain management doc and a diagnosis of CRPS / RSD has been confirmed.  I am very grateful because without your input, there is no telling how long it might have taken me to get an accurate diagnosis.  It does not seem to be very well known among doctors.  Now I have the opportunity to move forward with treatment / management.  My question is:  what role does a podiatrist play in treating CRPS?  My current podiatrist does not appear to be familiar with it at all.

I'm including a few photos from three weeks and nine months (last photo) post-injury, in hopes of educating people on what CRPS can look like.  Perhaps someone else will have the opportunity for a much-earlier diagnosis.

Thanks again for your help.
Forever grateful,

Marie

Dr Blake's Response:

     I am so happy to have helped since making the diagnosis is crucial to getting the right treatment. You will see from my blog that treatment should be a Team of people, with a podiatrist helping. A sympathetic block is typically important now, but oral medications can crucial. If you see my checklist of treatments for CRPS, you will see how creating a nerve non stimulating environment is crucial. The podiatrist, if knowledgable on this condition, will be invaluable along the way. Also, definitely check if you have a Calmare Pain Therapy center near you. Let me know how I can help further. Rich

And here is info from an article I am writing. 

4. Lessons learned from the treatment of Complex Regional Pain Syndrome

I am treating many patients right now with a diagnosis of Complex Regional Pain Syndrome. It is a very difficult topic, and one I have known for a while I needed to present somewhat on my foot blog. It is a gross understatement to say I am treating them, since they can only be treated by a team of people since it is too complex. The most important person on that team is the patient, and they really call the shots. If you are given that diagnosis, also known as Reflex Sympathetic Dystrophy or RSD, and others, you are scared. The doctors and therapists who treat you are scared for you. The quicker the response that better, but even those whose diagnosis is made at a snail's pace can get better. I love to see these patients every 2 weeks since there is so much to do and get organized. The visits should be a constant exploration and expansion of these Mainstays of Treatment: Identifying the source of pain, completely eliminating the pain cycle, nutrition, rehabilitation of limb function, being as productive as possible, and handling comorbidities of anxiety and depression. I hope this summary does help those suffering make sure nothing is being forgotten, and every visit to the managing doc is as productive as possible.

The Mainstays of Treatment are:

·       Identifying Source of Pain

1.      MRI/CT Scans

2.      Bone Scan

3.      Diagnostic Injections (local or back)

4.      Nerve Conduction Studies

5.      Lab Tests

§         Sed Rate

§         CBC

§         Free T4 and TSH

§         Vit B12 Levels

§         HgbA1c

§         Morning Fasting Blood Sugars

·       Completely eliminating/breaking the Pain Cycle

1.     Mechanical Means

§         Roll A Bout

§         AFO

§         Crutches

§         Tibia Wt Bearing Braces

§         Activity Modification

§         Custom Made Orthotics to stabilize an injured area

2.     Oral Medications

§         Anti-Seizure (ie Lyrica)

§         Anti-Depressant (ie Nortriptyline)

§         Others through Pain Management Specialists

3.      Topical Medications/Applications(should be gels for ease of application)

§         Warm Compresses

§         Non Painful Massage

§         Parafin Wax

§         Chinese Herbs

§         Lidoderm Patches

§         Neuro-Eze

§         Multiple Compounding Medications which include (usually not all of these):

ü      Ketamine 10%

ü      Clonidine 0.2%

ü      Gabapentin 6%

ü      Baclofen 2%

ü      Nifedipine 2%

ü      Lidocaine 2%

4.     Alternative

§         Biofeedback (Thermal to increase circulation)

§         Hypnosis

§         Meditation

§         Accupuncture (can be to opposite limb or ear)

·       Nutritional (next 3-12 months)

1.      Lipoic Acid 300mg 2x/day

2.      Acety-L-Carnitine 2000 mg/day

3.      Inositol 500-1000mg/day

4.      Vit B6 50mg/day

5.      Vit B12 1000mg/day

6.      Vit E (up to 1,600units/day)

7.      Thyroid Natural Supplements

·       Rehabilitation of Limb Function

1.      Lower Extremities (keep strong as long as painfree)

2.      Core (support feet and legs from above with less pressure on feet overall)

3.      Cardio (improve overall circulation and health)

4.      Whole Body (must address physical, emotional, spiritual sides together)

·       Being as Productive as Possible (while nerves are healing) Can Help Nerves Heal Faster

1.      Part Time Work

2.      Volunteer

3.      Projects

·       Dealing with CoMorbities of Anxiety and Depression

Possible Sources of Information/Support/Inspiration

ü      American Chronic Pain Association

ü      American Academy of Pain Management

ü      Reflex Sympathetic Dystrophy Syndrome Association

ü      How To Cope With Pain blog