Resolution of Foot Nerve Pain: Email Advice

Rich,

You asked for 2-week feedback on my heel problem (https://www.drblakeshealingsole.com/2018/05/foot-pain-from-hamstring-stretch.html), but I had some delays waiting for Neuro-Eze and traveling over Memorial weekend, so here's my 3-week feedback on the neuropathy.

I was impressed with your question about low back and sciatica because I do have a recently collapsed disc L4-L5, and experienced sciatica for the first time in the LEFT hip and leg in April. That faded away in a few weeks, then the heel problem manifested in the RIGHT heel, triggering by stretching, but I assume it could also be due to the damaged lumbar disc and sciatic nerve.

I strictly limited my walking, switched from your permanent orthotics (thin foam) to your temporary orthotics (memory foam) for their rearward arch placement and heel cushioning, and followed your treatment instructions (neural flossing, Neuro-Eze, knee-bent lifting, warm water) rigorously for three weeks. Heel pain was gone after two weeks, but I continue to feel the occasional twinge when barefoot on a hard surface or inadvertently stretching the achilles.

After 3 weeks I switched back to permanent orthotics and have walked about 5 miles since, resulting in no pain but again, minor twinges in the heel. My feet seem to be missing the arch and cushioning of the memory foam orthotics, which really relieve pressure on the heel!

Questions at this point:

1. How long should I continue the neural flossing and Neuro-Eze, considering that pain has been gone for a week?

Dr. Blake's comment: Thank you for the wonderful feedback!! Once the nerve is irritated at the lumbar spine, or along the sciatic nerve, the abnormal sensations called dyskinesias can linger for quite awhile (meaning months and months). You sort of have to pay attention, but you sort of do not. I like the Neuro-Eze three times a day for two weeks longer than the pain, then one month at twice daily. The self-massage is probably as important at this stage as the medication itself. Consider the neuro-flossing through August 1st (almost 2 more months because that gets the basic problem of the sciatic nerve settled down). 

2. Do you see any issue with using the memory foam orthotics? Dr. Blake's comment: No, you can continue with the full-length Hannafords, unless it upsets some other problem. Sounds like it helps the heel the best, and that makes sense, between the heel cushion and the transfer of weight into the arch off the heel. 

3. In the short term, how much is this neuropathy likely to be affected by walking? Should I be really cautious about resuming activity? Dr. Blake's comment: Walking should be wonderful as each step is a rhythmical neural floss. Possibly the stress on your back may be worse up or down steep hills, but I am not sure. Just go easy on hills. 

4. What about stretching? When and how can I resume (cautious) back stretches, hamstring, calf, etc.? Dr. Blake's comment: This I would bring up to a physical therapist. I know when I herniated my disc, they were cautious about stretching for several months, but that was in the acute phase. It depends where most of the tension on the nerve is: sometimes calf, sometimes hamstring, sometimes piriformis, sometimes low back. Just know that prolonged stretch can trigger it for awhile, but it sounds like it is relaxing fine. You can do short 10 second stretches with less pull than normal first to see how you feel. I would wait until July probably. 

5. What about long-term? Is this sort of condition likely to recur, or to limit my activity permanently, without more aggressive treatment? Dr. Blake's comment: I would not expect any long-term disability. I play basketball several days a week but have some dyskinesias from time to time. Months and months can go by without issues. Make sure with your back issues that you are fully rehabbing your back on a daily basis. Hope this helps. Rich

Thanks again!

Foot Pain from Hamstring Stretch: Probably Nerve Irritation

Rich,

     Your treatment plan for the fractured sesamoid in my left foot is going well, especially since I got Dr. Jill's 1/4" felt met pads, which work better with your orthotics than the 1/8" felt I was using for months. I've been able to increase my weekly walking distance gradually to about half what it was before the injury, but last week I suddenly developed a new problem in the right heel which has immobilized me again.
Dr. Blake's comment: Thank you for that feedback. I will try to tell all my sesamoid patients to experiment with the Dr. Jills product, even with their orthotics. So happy you are off the long plateau you were on. 

     Before starting a hike, I was doing a standing hamstring stretch with leg elevated onto the tailgate of my truck (I had already done my other stretches, including the "wall" stretch for calves). Toward the end of the stretch, I flexed my toes back toward my knee, and when I set my foot back on the ground (wearing heavy hiking boots and orthotics as always), I felt a sudden sharp pain in my heel.
Dr. Blake's comment: This is nerve irritation at the end of the sciatic nerve branch that feeds the bottom of the heel. The sciatic nerve is most stretched, and potentially irritated, with the hip flexed, the knee straight, and the ankle bent. Maximum stretch. It only takes slightly bending the knees or not pulling up the foot towards your chest, or both, to relax the nerve. So, you irritated the nerve deeply. 

Here similar situation with hip flexed, knee straight, and toes pulling up towards knee

     I had no idea what was happening and went on with my hike, being super-mindful about walking slowly, taking short steps and trying to focus weight away from that heel and onto the arch and toe, meanwhile just feeling discomfort in the right heel rather than outright pain. But the next morning when I woke up, I couldn't put any weight on that heel without bad pain.
Dr. Blake's comment: Have you a history of sciatic on that side or any low back or spine in general issues? These can be the first low grade irritation, that makes the sciatic nerve grouchy, but the stretch does you in. Nerves love motion, not prolonged stretches. 

     I ALWAYS wear your orthotics with the heavy boots, except when in the shower, and I've been really good about stretching, so this new problem really stumps me. The pain is under the center of the heel, and gets worse as the foot flexes and the back of the leg stretches (e.g. when doing a "wall stretch"). You say on your blog that PF develops slowly, so I initially thought it might be bursitis. But I don't do anything that results in impact on the heel - all I do is walking. And the pain seems to have been triggered simply by a routine stretching movement.
Dr. Blake's comment: Yes, see my video on neural flossing, get some Neuro-Eze to massage 3 times a day, avoid  low back, hamstring, or achilles stretching until it is better. Lift everything with your knees bent. Soak in warm water to see if it helps. Give me feedback within the next 2 weeks. 

I've been doing the ice bottle roll combined with mild stretching for a week with no improvement. I understand these things are sometimes tough to diagnose, but in any event I haven't had good results with our local podiatrist and thought I'd run it by you first. Feel free to post to blog if desired.

Thanks,



https://youtu.be/E0E60NpOSHg

Lower Extremity Nerve Symptoms: Looking for more than one Source

https://youtu.be/_7qNgYNUrmw

This was a comment to my You Tube video which I see often dealing with neurological problems in the lower extremities. There can be 2 or 3 sources of this neural tension that in themselves are minor, but together cause major disabilities. The treatment stems from finding all the possible triggers like poor posture sitting, overpronation of feet, poor core strength with low back issues, piriformis syndrome, etc, etc. I have had patients where the 2nd source of nerve irritation was the neck area, and the foot symptoms would not resolve unless the neck was stabilized somehow.

Hi Doctor Blake, I have a buzzy sensation in the ball of my foot when I walk. It began 10 months ago when I was running long distance. I had a variety of symptoms and was unsure where the pain was originating. It resulted in me developing a strong limp because I was in so much pain. I have had electric shock type pains travelling up my left leg, numbness in the ball of my left foot, pins and needles in my calf, tightness in my hamstring and glute. I have also had varying degrees of back discomfort but not enough for the doctor to think it is sciatica. I can't pinpoint a painful point in my foot and foot specialists haven't been able to either, although it does feel buzzy after it has been manipulated. I have had a steroid/anti inflammatory injection that didn't do much for me. The best thing has been some orthotics that raise my arch taking the pressure of the ball of my foot. I get the buzzy feeling by tapping the tarsal tunnel by my ankle as you demonstrated. What does this mean? Thanks,

Dr Blake's comment:

Low Back Pain and Orthotic Devices: Email Advice

Hello Dr Blake-

I have severe lower back pain and disc disease. I noticed my lower back at sacrum is twisted to the left and my left hip sways to left and my right ankle pronates with nerve pain between right large toe and second toe. I am walking with a cane in the morning my back is badly twisted in the AM

I found a pair of orthotics that were  custom made at the Saint Francis Sports Med Clinic decades ago. I started using them yesterday and the pain has greatly improved and I can walk up steps now with increased strength and reduced pain.

My question is would you be able to to make a new pair of orthotics for my back pain  since it has been so long? I do not know if a podiatrist provides this service for back pain.I was diagnosed with scoliosis as a child and I have always pronated.

Thanks-

Dr Blake's response: 

     Thank you for the email and I will be happy to re-eval your biomechanics. The low back (in fact the whole body) loves symmetry. Sounds like you pronate more on the right and that becomes a high priority to level the pronation between the two sides. You actually need some pronation in your feet for shock absorption, but it is my job to eliminate the excessive amounts, or the abnormal positions, or at least the asymmetry. I have many patients with low back pain helped with pronation control, or just good biomechanics, since excessive supination (AKA underpronation) is one of the commonest causes of low back pain and of course treated opposite of pronation control. 

     When you are dealing with the low back and biomechanics, you always need to look at structural, functional, or combination short leg syndrome. This causes the base of the spine to be always tilted at L5S1. The body will need to constantly fight this to right itself, and muscle spasms in the low back can be produced. We will check for this also. 

     The pronation control you are experiencing is probably some version of "double crush" syndrome. If your low back disease is causing nerve irritation, even slightly, you can get symptoms down stream when there is a second irritation to the same nerve, thus double crush. The foot pronation, when excessive, can irritate the tarsal tunnel at your ankle where the posterior tibial nerve lies (a branch of the sciatic nerve). Controlling that pronation can relieve these symptoms, as it seems to have done. 

     There are so many other helps for your low back including: sitting posture, sleeping concerns (mattress), tight hamstrings, etc. A back specialist into rehabilitation should always be part of the team. In San Francisco, Dr Robert and Irene Minkowsky do a good job at analyzing and treating these pelvic tilts you describe. They are at 2000 Van Ness Avenue. You describe an anteriorly rotated right pelvis to the right (possibly from pronation or weak external hip rotators like the iliopsoas) with a laterally externally rotated left pelvis. The source of these rotations can come from the foot, hip muscles, sacro-iliac joint, or scoliosis. Sorting them all out is funner for the health care providers than the patient, but it your symptoms improve, you will being to have fun also. It will be good to see you. Rich

Calf Pain with other symptoms: Email Advice and Response to Neural Flossing

Dear Dr. Blake,

     I have been studying your blog for a few weeks now and enjoying your expertise and caring manner.  I wish you could be my Dr,  I am looking for advice on how to direct my podiatrist appointment in 9 days.  I will try to make this to the point.  10 yrs ago I stepped down on a rock while saving my son from an active dog and got a stress fracture on my sesamoid. 

    Wore a boot and orthotics made by podiatrist. In the last 6 months I began having knee/calf pain and my sesamoid toe - the big one - was acting up.  Podiatrist took xray and didn't see fracture and added a dancer pad to my orthotics.  The sesamoid started feeling better, but I still had the mild calf/knee pain and the ball and heel of my foot hurt when I walked barefoot.  The pain was bothering me enough to take ibuprofen. 

    5 weeks ago I reached up in a standing position and I couldn't bear weight on my foot due to extreme calf pain.  I was unable to stand on my tippy toes.  Podiatrist sent me home with 1500mg nabumetone and said to come back in 2 weeks diagnosing me with tarsal tunnel after pushing on foot with his hand to find pain points.  I began physical therapy 2x a week.  

    Eventually I was able to walk but not without pain.  The med prescribed made me tired and my belly hurt so I took ibuprofen instead.  At my 2 week appt with podiatrist he offered me cortisone telling me it was more diagnostic to find out where to operate or a cam walking boot.  I chose the boot - that was 3 weeks ago.  Last week I took off 5 days off my part time custodian job, took the med prescribed and layed low icing and resting.  Felt much improvement, but still unable to walk barefoot due to heel/pad/calf pain. 

    Back to my 2nd day of work wearing my boot and the calf pain is getting worse.  I did get a 2nd opinion last week by an orthopedist and he acted as if I wasn't telling the truth about my pain.  I am looking for help with my next podiatrist appt.  I understand that sesamoid can cause other issues - I also pinched a sciatic nerve on same side of body after recent sesamoid pain.  I know that cortisone will be my next option and it scares me. I am not confident about the diagnosis of tarsal tunnel.  The Dr. said he could do other tests but they wouldn't tell him much. 

    Am I correct that if I get injected in the wrong spot that I could have other problems?  I am somewhat mobile now and have no interest in making the problem worse.  I understand that cortisone is a band aid to the issue and the shot itself truly freaks me out.  Would you recommend an mri or any other tests to make my diagnosis more concrete?  If I truly have tarsal tunnel I believe the Dr. wants to do surgery and resources online say I have a 50/50 chance of being better.  The recovery of surgery seems miserable and I really don't want to be immobile.  I have already given up the gym I went to 4x a week.  When I spoke with orthopedist about the sesamoid/sciatice nerve issue playing a part in my current issues I got a blank look.  I want to go to podiatrist armed with information to help me make the best decision for myself.  Can you help me?

Regards,
Toni (name changed)

Toni,

      I am out of the office until 9/29 and will try to get back to you that week. Rich

Hi Dr. Blake,

     I got a 3rd opinion yesterday and he thinks baxters neuritis and planters fascitis.  He listened to my ideas of right side issues and I am having an emg.  I believe this podiatrist will help me get to the issue of my pain.  Writing to you and reading your blog has helped  get my brain in order to advocate for a correct diagnosis.  Thank you for being there to help me get this into words.  I will follow up with you once I get emg results.  

Enjoy your time out of the office

Hi Dr. Blake,

    Thank you so much for your blog.  It has empowered me to find a doctor who takes my pain seriously.  I had an emg done and there are no nerve issues.  I've been diagnosed with plantar fascitis and peroneus longus tendonitis. After reading your information on these issues it makes sense.  I believe I have found the right diagnosis.  I am off work for 2 weeks and now have a night splint along with the cam walker.  Dr. also prescribed me a cream compound with lots of meds to help with pain and blood flow.  I am also going to continue with physical therapy.  Unless you feel the need to respond I'm ok with studying your blog on these issues and taking your advice.  I appreciate your information so much and hopefully I will be pain free soon.  Take care.

Dr Blake's response finally: 

     Toni, thank you. I am back from the Greek Isles (someone had to go) celebrating my wife's big #__ birthday (intentionally left out number). I am so happy you found someone to listen. Tarsal Tunnel diagnosis is so difficult to make that considering injections and surgery for this needs to be very well thought out, with numerous opinions. With your history of sciatica, and the nerve hypersensitivity that can linger, you can have symptoms all along the course of the nerve leading to many mistaken diagnoses---from metatarsal pain, to arch pain, to heel pain, to ankle pain, to calf pain, to pain in back of the knee or thigh or butt. Changes in your gait, especially over supinating (or rolling to the outside of your foot), can trigger sciatica. This nerve hypersensitivity does not mean nerve damage, and that means the nerve testing (conduction or emg studies) can be negative. This severe calf pain that you had is typically only produced by nerve pain or blood clots, so if the calf pain gets bad again have a doppler ultrasound of your calf to rule out DVT (deep vein thrombosis). Your treatment right now makes sense (activity modification, protected weight bearing, and physical therapy). Eliminate all that sets off any pain. Do neural flossing from my blog for several days to see what symptoms it helps or irritates, but hopefully it is very relaxing to the sciatic nerve. When you stretch the calf, and you should 3 times a day, always keep your knee slightly bent to protect the sciatic nerve. As the pain calms down, all of the secondary symptoms should go first, with the pain from the main injury lingering. Daily keep track of what hurts (say at the end of the day) that day. You hopefully will see a pattern. The problem you face, when you have many symptoms, is that the docs and physical therapists can spend a lot of time treating secondary symptoms, and lose track of what is important to treat consistently. I sure hope this helps somewhat and thanks for all your kind words. Rich

Patient Response:
     Dr. Blake,

Thank you so much for taking the time to help me with my issues.  The neural flossing helped tremendously! The first time I did it my hip cracked every time and I knew we were onto something.  After first day the throbbing in my foot/calf stopped and my hip hurt like crazy.  After 4 days I was able to walk more comfortably and I only have pain in my heel when I walk barefoot.  I saw a chiropractor and he found issues with my L5 and other things.  Today I am returning to work!  If I hadn't done the exercise I would have been strongly been considering cortisone in my foot due to being tired of the pain.   I believe you helped me avoid the unneeded shot and I am grateful.  I have an appointment with my podiatrist and I'm not sure I need to go.  I would love to share this information with him, but not sure it's worth the office visit.  

You are a good man for sharing your knowledge with the world.  I will find a way to pay it forward.  Thank you so much!

Double Crush: Back to Foot Connection

Dr. Blake,

I found your blog and need some advice if you have a minute.

I have pretty bad lumbar back problems. MRI has shown lots of problems from L3 down to S1. I was referred to a pain doc for 3 rounds of steroid shots. She took new pictures and said it was time for me to see a surgeon.

At the same time I have numbness in my feet. Bad in the right. Swelling/pain in ankle, etc. Went to foot doc and was diagnosed with tarsal tunnel and neuroma. Have this in both feet, bad in right, left is manageable. He said my shoes were to narrow causing the neuroma and my high arches were falling causing the tarsal tunnel.

Basically, I'm a mess and in pain all the time. Lower back and ankles/feet. Hard to stand for very long.

I was googling and found "Double Crush" which links the lower back problems and the tarsal tunnel problems.

I need advice because I don't know how to proceed. I've tried everything, shoes, expensive orthotics, compression socks, stretching, exercises, chiropractic, massage, and others. I was prescribed shoes, orthotics, compression socks by foot doc. I was prescribed drugs (They want me to take Lyrica) by the neuro sergeon. 

I'm frustrated and frightened because I'm just turning 50 and I concerned this is only getting worse. I don't know if I should see another foot doc or another back doc or what to do. I need my foot doc to talk to my back doc and discuss this problem together because my reading indicates they are related.

I'm also confused on the orthotics because some of my research shows, yes do them, other reading indicates they may be causing some of the problem and I need to go natural. I believe there is a connection and my alignment from my feet up to my back is out of wack and I don't know were to turn.

Any advice?

Frustrated and in Pain from San Antonio, TX

Dr Blake's response:

     Thank you so very much for your email. Lower Back irritation to the nerves that go to the foot are unfortunately very common. I am a biomechanics expert. I need to see if I am dealing with a musculo-skeletal problem, or a neurological one, since the treatments may vary at times.

     You want to try to avoid foot surgery, if suggested for neuroma or tarsal tunnel, until the low back component has been worked on considerably. But, you still need to treat the foot locally.
Golden Rule of Foot: Treat the Low Back Nerve Component First to see what the Role in the Foot Pain.

     You are so right to want a team approach. Typically, this is a physiatrist, who can work with the medicine/epidural side, but knows what the podiatrist is doing, and what the neurosurgeon has to offer.

     You are in a nervous system overload right now. You should maximize support to the foot and low back (orthotics, foot strengthening/taping, core strengthening, back braces), and ways to minimize nervous irritability (oral meds, topical meds, warm soaks, neural flossing,etc.). I never recommend avoiding medications in this scenario, since you have to get the nervous system calmed down, and it can take a long while, getting the medications right. 

     Definitely, the role of orthotic devices to stabilize your lower extremity, and lifts if you have a short leg, are a no-brainer to me. Find out who makes the best orthotics in your area. Have your doc prescribe a Standing AP Pelvic Xray to document the leg length difference standing (I have some posts in my blog on this). Treatment of a short leg is Back Pain 101 to me. Most definitely recommend surgery for the back if the nerve injury is causing weakness in your legs, but waiting a month or two to get orthotics that make your feet function symmetrically and lifts for any short leg make help considerably. 

     I sure hope this helps somewhat. Rich

     

Back and Foot Correction: Email Correspondance

This is an email from a patient whom has done well with her orthotic devices to stabilize her lower extremity, but now seem to be having problems. 

I have recently had an odd thing happen with my feet/orthotics. Over the last several months I have had increasing problems with my right hip/ITB. Rolling on the styrofoam roller helps but won't get rid of it. Used trigger point therapy in upper quads; that helped  but didn't get rid of it. Ended up with very sore muscle around fascea lata (sp?). Then hip itself got sore. Found that if I went barefoot, it went away. Did that (as much as I could) for a few days. Noticed that my left achilles was very tight and sore...maybe got stretched too much going flat-footed?

Of course I had to wear shoes but did better wearing the sandals, without orthotics.

A couple days ago, my lower back started to hurt so I tried to wear orthotics more.  In my work, I am on my feet for up to two hours at a time; sometimes it's only once a day but other days I do it a couple times, but with breaks in between. Yesterday, I hit a wall. My hips were so sore and then my left medial gastroc muscle started spasming. It  also seemed to come from the crease in my knee in the back. This feels a lot like what happened initially (which included my popliteus muscle), many years ago in my right leg, that lead to my plantar fasciitis. Which my orthotics seemed to cure.

Problem now is that if I wear any shoes at all, it is painful/difficult to walk using the affected leg, left one. Orthotics in tennis shoes of course are worse than wearing my sandals which have fairly good arch support but less than orthotics. But even the sandals make that muscle cramp. 

I am taking it easy, both with my back and my feet....using ice and naproxen.

The only other thing I had been doing differently just before this calf muscle event was trying to stay aware of not locking my knees. I thought I had licked this one years ago but last week a Pilates coach said I was still doing it. So I have been trying to keep knees slightly bent when I think of it.

I remember once you told me that my feet sometimes hurt, (it feels like the arch in my orthotic seems too high) because my back is shifting and there is something wrong up there, rather than my feet being the cause of that kind of pain.

I am wondering if you have any insights as to why I might be currently experiencing this increase of pain in my calf when I use any kind of arch support? 

Thanks

Hey Tina, sorry for your dilemma. One possible cause is that a branch of the sciatic nerve, coming off your back, going behind the knee into the calf, and finally the arch is irritated. You may have been slightly irritating with the knee hyperextension, and perhaps you have a slightly bulging disc.When these nerves hurt, it is hard to wear arch support which presses into them. I would see a physiatrist, like Dr Irene Minkowsky, to look at the whole neurological chain from spine to toes and see if there is a simple place to start treatment. I hope this helps. Rich

Nerve Pain: Email Advice

Hi Dr. Blake,

I have been following your posts for months now.  Hope you can help in even giving me direction and whether seeing you or a different kind of doc would be best next step.

Out of the blue in Jan., I noticed a constant nagging sensation like my sock was uneven on bottom of left foot/big toe and irritating it.  When I took off sock, the foot was bright red, swollen and painful to touch esp. in the metatarsal area and more so on middle joint of big toe.  There also seem to be a lump on that joint and when I even lightly touched it, would send a radiating pain up my leg, into my back and up the right side into my neck.
Dr Blake's comment: You are talking about the femoral nerve which has a branch to the big toe and can radiate like that. I am assuming that something from that joint irritated the nerve causing the nervous system breakdown. 

And once the pain was activated, my entire central nervous system went into hyper gear and it was impossible for me to bring it down -- with many different supplements, topicals, even meditation, etc.  The other piece that went hand in hand were areas on ball of foot and around the big and second toe that were blue and even pieces of vein protruding that were the most painful areas.
Dr Blake's comment: This is sounding like RSD, which stands for Reflex Sympathetic Dystrophy.

Most of the acute symptoms have improved or disappeared since then although still some lingering issues that prevent me from going on a walk or doing even simple activities.
Dr Blake's comment: Sounds like you managed to create a nice pain free healing environment that is so important when the nervous system is barking soooo much!!

Since Jan. I have gone to a couple of different chiropractors who not only use activator, they also use techniques to break down fascia issues.  One thought that the major issue on big toe might have been capsulitis which also might be putting pressure on nerve.  I also went to osteopath.  He thought it was bursitis on big toe creating all the problems.  Also went to 2 different individuals that specialize in chiropractor neurology.  Their exam showed that the constant radiating pain had to do with pain center in brain not shutting off pain signals and my central nervous system had a hard time shifting to parasympathetic system.  Also X-ray of foot and back where taken.  No fractures in foot.  I have spinal stenosis I believe at L4/5 which I understand can trigger pain in first/second toe(???).  Also I do have a flat arch in the problem (left) foot.
Dr Blake's comment: This is helping with the whole picture. The L4 nerve root goes to the big toe. If this nerve is irritated at the back, and then irritated at the foot, a "double crush syndrome" occurs and the nervous system is very unhappy.

Practicing natural healing for decades, I have also done lots of remedies -- including vit. c, msm, an anti-inflammatory supplement with proteolitic enzymes, vit. B, B12, lion's man (medicinal mushroom for regrowing nerves), calc/mag + magnesium chloride (liquid and gel), comfrey compresses, castor oil compresses and the list goes on. I have also worked with feldenkrais practitioner and also try to stretch when id does not aggravate pain.
Dr Blake's comment: Neural Flossing or Gliding is great and relatively new to physical therapy world. It is a gentle way to stretch the involved nerves, not allowing scar tissue or swelling to collect around them. On my blog I have a video of one sciatic nerve flossing technique. 

Since Jan. I have not been able to use my customized orthotics, as areas where raised, trigger pain so I have gotten a cushy "not customized" orthotic from Walking Shoe Company that molds to foot and provides arch support.  That seems to work for now and does not trigger pain.
Dr Blake's comment: This a great idea, you have to remove any abnormal nerve stimulation.

I tried walking about 12 min. on dirt on Sunday (first time I tried to go for short walk) and couples of hours later I felt increased pain sensitivity.  Not unbearable,  rather a reminder something is still going on and simple activities still problematic. In Jan. pain level and intensity were probably a solid 10. now about 2-3 as long as I keep walking to minimum and not engage any other activities to aggravate it.

Sorry about long email.  Final comment .... being self employed, I have a very high deductible which essential means all of my medical expenses are paid out of my pocket.  Unfortunately, that piece does enter the equation of what I can do.

Thanks,
Deb (name changed)

Dear Deb,

     Thank you so very much for the email. You sound like you are at where one of my patients is right now: Wanting to remove the source since it could trigger it all over again. I do not blame you. You may have to save up your money so when you feel free to spend through your deductible (next year???) you can get the MRI or CT scan to identify the lump in your foot, and treat it. At the same time, you need to work on your back to get that as stable as possible (less chance irritating the L4 nerve root. All this can easily max a high deductible quickly, leaving 11 months to have the insurance doing the rest of the paying. I am so proud of how you dealt with the initial flare of RSD. Please send me 5-10 bullet points on the key things you felt were crucial getting this to 0-2 pain. Rich

Plantar Fasciitis and Achilles Tendinitis: A Common Duo

Dr. Blake, I found your blog online and found them a fascinating read. I wonder if you can shed some light on my foot problem. I have plantar fasciitis on both feet and Achilles tendon insertional micro tear (insertional Achilles tendonitis?). I have had them for more than a year, been seen by my podiatrist 4 times. I am still in pain from both problems.

• Nov. 2011.       started noticing pain in bottom of right heel at the first steps of the morning

• Nov. 2011.       took Ibuprofen for 2 weeks per primary doctor’s advice and stopped daily 2-mile run since then on

• Jan. 2012,       while the condition of right heel is getting worse to 8 out 10 pain scale, I started noticing pain in bottom of left heel at the first steps of the morning. I started wearing orthotics since then.

• Feb. 2012.       seen by a Podiatrist. Was told to do regular stretching.

• Mar. 2012.       over stretched the Achilles tendon/heel bone insertional area. Having pain in the insertional areas of both feet since then. Stopped stretching since then.

• April-Sept, 2012, elevate my feet as much as I can during the day. Ice them before I go to bed at night. Symptom is getting better. Pain level improved 5 out of 10 scale.

• Dec. 2012.       Started arch stretch. Plantar fasciitis pain appear to get better, but very slowly

• Feb. 2012.      Started to massage calf muscles, plantar fasciitis pain appear to get better, but very slowly

• March, 2012. Started to have a lot more pain, new pain, in the lateral side of the heel of both foot.

• My doctor told me to stretch the calf muscle. But even a very gentle stretch will cause the insertional area quite painful.

I wonder whether there is any cure for me? Thank you.

Dr Blake's comment:

     Thank you so very much for your email. I am gradually catching up from before my little Hawaiian vacation, so I apologize for my delay.

Sunset from Waikiki Beach, Oahu, Hawaii

Most people know that the plantar fascia on the bottom of your foot originates from the achilles tendon fibres that engulf the heel bone. If you are lower on the evolutionary change, there is a greater connection between these 2 structures. Apes can use their ankles like hands so need these two structures connected. So, no matter where you are at  in the evolutionary process, you can develop pain in one structure first, then another. This, in your case, is what is being treated. But, is it correct? You can consider the achilles tendon fibres grabbing the heel bone from the back, both sides, and bottom (like a hand), ready to lift the weight equivalent to 10 times your body weight. And, it is hard to stretch the insertional achilles fibres into the heel bone since they are attaching into the bone. Typically stretching and massaging, if not done perfectly, can irritate the fibres more than bring them relief.

As you are being treated for tendinitis/fasciitis, and it is not working well, there are 2 logical explanations. The treatment is just not tailored enough (individualized) to you or the treatment is not addressing the correct diagnosis. First of all, both the plantar fascia and the achilles tendon attach into the heel bone (calcaneus). This could easily be an injury to the heel bone with pain from protection or compensation in the  plantar fascia and achilles. So, I would look into obtaining 3 tests that can greatly help with the diagnosis: x rays, an MRI, and a bone scan. The x rays have the least likely chance of helping, but they may point to something important. Even if you had to self pay for these tests, the $1200 (San Francisco Bay Area prices) would be worth it. This would 100% rule in or rule out a bone problem that needs to be dealt with differently than you are treating yourself. 

Second of all, the plantar fascia and achilles have fibres of the sciatic nerve running through them. I have personally misdiagnosed sciatic nerve problems as plantar fasciitis and achilles tendinitis numerous times. It is easy to do, but when the patient does not respond to normal treatment, you look deeper. Neurologists and physiatrists are the nerve test people. See if they can make some correlation to your pain and the sciatic nerve. This may require a nerve conduction test. Treatment for this syndrome also quite different. The sciatic nerve hates to be stretched, but the technique of neural flossing may work. 

Finally, perhaps the treatment you are getting for achilles/plantar fasciitis is not correct. When you have any type of tendinitis, see my post on BRISS. This stands for Biomechanics, Rest, Ice, Stretch, and Strength. It is the 5 areas that should be addressed simultaneously in treating any tendinitis like achilles tendinitis and plantar fasciitis. You make changes in the biomechanics of shoe gear or activities, you use rest or activity modification principles to keep the pain level between 0-2, you use ice and other anti-inflammatory measures to calm the tissue down, you do pain free stretching, and you begin arch and achilles strengthening the day you begin to have pain. Go back to square one with your rehabilitation. See the link on BRISS. Read all the posts regarding achilles and plantar fascia. Get some of the above mentioned tests to rule in or out other causes of heel pain. I sure hope this points you in a good direction. Rich

http://www.drblakeshealingsole.com/2010/06/briss-principle-of-tendinitis-treatment.html

     

Nerve Pain: Double Crush, Diabetic, Low Back??

Hi,




I have had severe sharp stabbing and burning left foot pain for some time now. I was tested twice for neuropathy and found I am showing signs of it. A slight increase shown in the last test from the first which was three years apart. I am a Diabetic, not on insulin but taking 1500 mg of Metformin/day. I also have sciatic problems but mostly in my right foot. I blew out my l5-s1 in 1991 and had surgery to fix it. 6 moths later I was at the GYM working out on a machine and felt my right foot go numb. I put up with it ever since. I have been to three different Doctors about my pain. One claims it’s my neuropathy, another says it’s my back injury, and the last doctor (and current one) says it is Tarsitis. He gave my a shot in my ankle which took the pain away. BUT, it came back after two weeks. He gave me another shot but it only lasted four days. The pain is getting worse, keeping me from sleeping. Ice dose not work anymore. The pain is on top of my foot and on it’s left side looking down at it. It is also into my small toes. Seems to travel from in front of my ankle to my toes and wraps around the left of the foot.

No body has done an x-ray or a MRI. I am taking Lyrica which at first I thought it was helping but now the pain is worse.

Any suggestions?

John in PA  (name changed)

Dr Blake's response:

    Thank you so very much for the email. I am sure that there are some versions of Diabetic neuropathy that present like this, but it is an unlikely presentation and therefore not my top pick. However, it is a perfect time to make sure that your diabetes is under control. What is your HbA1c? Make sure it is below 6. You need to get a handle on what your neurological exam tells us. Please review the videos next.





So, from your description, and the 2 videos you can be dealing with a localized nerve (superficial peroneal or sural) or the L5 and S1 nerve roots, or both called the double crush syndrome. See the link below.

http://www.drblakeshealingsole.com/search/label/Double%20Crush%20Syndrome

The injection you got was very diagnostic in identifying what nerve was involved, but it still does not tell you if all or some of the pain is coming from your back. Please follow these steps.

1. Develop quickly a pain free environment, since nerve pain can get out of control. I personally had to get both an epidural and a sympathetic block since I could not calm mine down in 2004. I am presently nursing another back injury, and trying to be much better. 
2. Get to a back doctor to do back xrays, MRI, and NCS/EMG. You deserve all these things because of the severity of your problem.
3. Typically with nerve pain you are on some topical medication and oral like Lyrica. So, for right now ask about a topical and build the Lyrica gradually to 150 mg twice daily. 
4. Work on your diabetes by getting the HbA1c and fasting blood glucose. 
5. Use crutches, removable boots, activity modification, etc to get out of pain ASAP. 

 I hope this helps your direction. Feel free to comment. Rich Blake

Foot Nerve Pain: Does It Always Start in the Foot?

Yes, it was my birthday on 1/9. 

My great Medical Assistant Shawanna surprised me with a cake. 

This Standing AP Pelvic Xray shows that the right hip is 6 mm or 1/4 inch short with compression of the right L4/5 disc which can lead to pain in the nerve's distribution in the foot. 

See how the marker at L4/5 disc shows right side compression with lean of the lumbar spine to the right. This patient has Morton's Neuroma pain in the right foot in the 3rd metatarsal area, consistent with L 4/5 nerve pain.

The same patient above has a collapsed metatarsal arch also leading to possible nerve irritation at the foot level. The yellow line from the bottom of the 5th metatarsal to the bottom of the sesamoids should be the lowest points in the metatarsal arch. See how the 3rd and 4th metatarsal heads fall below this plane in your Plantar Axial Foot Xray. This patient could easily be irritating the nerve at the back and at the foot causing a "double crush syndrome."